Hazardous Hobby exclusions
JCInfo
41 Posts
I have an employee who is questioning the 'hazardous hobby' exclusion of our medical plan and am curious as to how many others have this exclusion? This employee feels that we are discriminating . . .
We have a self-funded plan (been effective for a couple of years now), but had a fully insured plan prior to that. The fully-insured plan had the 'hazardous hobby' exclusion in it as well.
Any thoughts and or guidance?
We have a self-funded plan (been effective for a couple of years now), but had a fully insured plan prior to that. The fully-insured plan had the 'hazardous hobby' exclusion in it as well.
Any thoughts and or guidance?
Comments
Thanks!
Care & treatment of such is an exclusion under the plan.
If this employee really thinks you are discriminating have him show you a plan that covers it. Besides, discrimination in and of itself is not illegal. It is only illegal when congress says it is so (as in sex, religion, race, etc).
Good luck!
Nae
Since this policy is driven by money, it's more logical to exclude people who smoke and don't exercise, along with drunk driving and not wearing a seat belt. Those activities pose a much greater financial risk to your health plan than my desire to hang-glide once in my lifetime.
Your policy rewards people for sitting on the couch eating Bon-Bons and punishes employees for being too athletic. That's a perverse message you're sending to employees.
And the list of horrible activities is going to be arbitrary. You exclude jet-skiing? That's a mainstream sport, hardly extreme.
Does your policy list all possible activities that will be excluded, or does the insurance company have the power to exclude things that aren't on the list? My friends and I jump into the lake from a 20-foot rock formation - can the insurance company decide after I'm hurt to exclude that? The answer has the potential to ruin my life.
Most of my friends and co-workers would be absolutely ruined financially by an uninsured accident. They'd lose their house, their life's savings, their kids' college fund - everything. You're willing to let that happen to one of your employees because they had the audacity to go jet-skiing? And you'll watch a co-worker get full medical coverage after crashing into a tree drunk? I couldn't do that.
Sorry for shooting the messenger, but this hit a nerve with me.
James Sokolowski
HRhero.com
I would like smokers to pay a much higher premium or agree to some kind of program to change their lifestyle. The same goes for people like me who are overweight, and those who are diabetic, etc etc etc. Actually, if we get going on this where do we stop?
The things you mentioned have become serious health issues that drive the costs up for all of us. But few deliberately and conciously choose it. For instance, a smoker is addicted. My hubby quit smoking 3 years ago (for the umpteenth time), but he still craves them. Every year his chances of getting a connected disease drops, but he is not out of the woods yet. Perhaps he should pay a higher premium which also drops as his health odds improve. But think of how complicated rates would get if we did this, and then how would we handle the ones who have genetic diseases?
A thrill seeker is a bit different. They deliberately choose to take the risk. It's not because they have an addiction, and it isn't something that snuck up on them over time. They put their life and limb at risk soley for the fun or thrill of it, and usually do it more than once. If they want to do that, I am ok with it. But they should have a separate policy and pay the higher premium instead of forcing me to pay for their fun.
Right now if you are a bit over the limit and hit a tree and die, your life insurance won't cover it. They will say you were driving illegally, and they don't have to pay. I am waiting for the health insurance industry to latch on to this fact and start doing the same.
As long as this insurance crisis continues, we can expect to see exclusions like the ones on this thread. Ok. Now I'm off my soapbox.
Nae
The health care industry is a very good enabler of people who are quick to claim "disease", but should be claiming "no will power". They are more than happy to label human weaknesses as diseases so that they can "treat" and then charge like hell!
I agree with most of what you said. However, I have to disagree with your sentence, "The things I mentioned are just as much of a choice as skydiving and cliff jumping."
People who have weight issues have to fight their demons every day. People who have addictions have to fight their desires every day. I know some people quit smoking and are ok, but others crave that cigarette the rest of their lives. People who have lost large amounts of weight will tell you that they don't just get over it, but it becomes a lifelong battle.
This is completely different from someone who just wants to have fun in an extreme way.
Having said that, I will acknowledge that for a few, thrill seeking is an addiction in of itself (in the same way other physchological additions exist). It is a very few. Most are just looking for their idea of a good time.
Anyone who has ever been fat knows that being fat is NOT a good time. I have tried I don't know how many diets, exercise plans, and different food regimens. I have even been hypnotized. I lose some and then gain it back, plus more. I don't deny that I have only myself to blame. But, if I could just walk away from it and choose something else as easily as someone who loves skydiving can walk away and choose something else, I would. For me anyway, it is NOT the same thing.
Nae
You make some excellent points. I will now take my lashings for being somewhat cavalier in my comparisons. I certainly don't minimize the daily struggles such as yours that many people endure everyday. I, myself, quit smoking 27 years ago. It was a bitch and you're right. Putting down the cigarettes is not the same as parking the jet ski. About thirty years ago I lost 45 pounds and have managed to keep it off. I devised my own diet plan and stayed with it, but it was a struggle because "diet" from Greek literally means "way of life". It's not temporary. If you would like a copy of it, I can send you one. I will warn you though. There are no secrets.
Nae, I personally wish you and your husband well in your fight with the vice demons. It can be done and you seem like the type, just from your writings, that you're up to the challenge.
I am always open to new ways to possibly get the weight off and keep it off. I sincerely believe that there has to be one out there that will work for me. It is just a matter of finding the right one. Please send me your diet.
[email]rdennison@century-health.com[/email]
Nae
I do see where you are coming from but the flip side of that is-should other participants in the 'insurance pool' be liable to pay for someone that has an accident doing an activity and/or hobby that is a voluntary activity? . . . I just pose that for arguments sake and to show you another perspective. Most would agree that coverage should be extended to cover treatment of injuries as a result of an auto accident, but there is auto insurance, subrogation and other coverage to consider as well. And most would agree that driving an auto is, in most cases, a necessity in this country. As someone who has gone through a personal tragedy with teenagers involved in an auto accident & facing upwards of $1.5 million in costs, I'm extremely grateful to my insurance carrier for covering the majority of the costs. I do know the driver of the car was not covered because of a reckless driving conviction . . . my daughters were passengers & were therefore covered. . .
Personal responsibility and personal liability is a big topic of conversation in the industry in regards to personal health habits, weight issues, disease management and smoking, just to name a few areas that are under scrutiny. Some employers (in states that allow it) exclude coverage for smokers if he/she will not quit in a certain length of time-(look up 'Weyco' in Michigan).
Wellness programs, which are very much the 'in' thing right now are looking at other types of compliance and/or exclusions too. Again, it goes back to whether or not all of the participants within a plan should be liable for someone else choosing to do a hazardous hobby, or choosing to engage in a hazardous habit, like smoking or choosing not to treat his/her diabetes properly or . . . and it goes back to personal responsibility & liability.
If I am tasked to look for the best options, coverage & premiums for the employee and the employer & I have an option to reduce the premium cost to the employee & the employer by excluding certain items, be it 'hazardous hobby' exclusions, or costs incurred for illness or injury while engaged in a criminal activity or acts of war (which we also have in our policy), shouldn't I look at all the options? Because we have a self-funded plan, my 'pool' is fairly small & I don't have the option of spreading the risk out over 1000's of participants.
So . . . ?
I've had some bad experiences with an insurance company that taint my view. And I like these types of sports, even though I've done very little.
What really bothers me is that the penalty for the employee can be extraordinarily harsh (financial ruin) while the criteria seem quite arbitrary. Jet skiing isn't more extreme than snow skiing or driving a motorcycle. And bungee jumping isn't stupider than cleaning the gutters on a two-story house on a rickity ladder.
Your policy draws a fine line between activities that have the same level of stupidity and risk and treats them totally differently.
Let's say you have two employees with injuries that cost a quarter-million each. One got hurt hang gliding despite taking all sorts of precautions and safety training. The other guy got drunk and tried to jump off a roof into a swimming pool. The stupid, drunk, reckless diver gets full coverage; the careful but unlucky hang glider goes bankrupt. That's not fair.
I think it's impossible to make exclusions like this without eventually getting some harsh, unfair results. The unfairness would be easier to swallow if the penalty was milder, like reduced benefits rather than losing your house.
But I'm obviously in the minority here, and I doubt I'll make any converts. You have sound business reasons for having exclusions like this, and you need to do what's best for your employer. But I hope my shrill rantings have at least made some people think about the opposing viewpoint.
OK, I'm done now.
James Sokolowski
HRhero.com
Cleaning your gutters on a rickety ladder is very stupid, but since the fall isn't as great as a bungee jumper (normally), I don't think they are equal. Actually, since I hate fast drops I have to say that nothing seems stupider to me than bungee jumping. But I concur that it is a personal point of view.
A few weeks ago (on tv) I saw a bunch of people jump off a bridge together trying to set some record for the most people bungee jumping together. Something broke and they hit the water with a bang. One had his neck broke, and another almost drowned, but no one died and the broken neck healed without any permanent paralysis. As I was watching them talk about their injuries (in almost a proud way) all I could do was wonder who was footing the bill. It was for sure none of the jumpers were.
I guess the real problem comes down to us all being individuals. Was the person on the ladder too stupid to know he shouldn't get up there (so it wasn't really a risk choice), or did he do it deliberately (in which case we shouldn't have to pay via insurance premiums)? Since we can never prove it one way or the other, we are all stuck. Unfortunately for thrill seekers, we CAN prove that they had a choice. It sucks green turkey feathers, but that's the way it is.
Nae
The only problem I have with excluding hazardous hobbies is whether the insurance companies are comparing that risk to an equivalent non-hobby activity. I don't have a problem with the choice to participate. If you know it's not covered, or think it might not be covered, and you still want to take that risk (bodily injury and/or financial ruin), that's your choice. Chances are that your once in a lifetime skydiving stunt isn't going to be done spur of the moment, so you've got time to check whether your choice of hobby is covered and then make an informed decision whether to participate. We do this all the time, maybe subconsciously, while driving a car or cleaning our roofs, anyway.