Human Resource Blog

Past High Insurance Claims

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One of our employees has had a history of high insurance claims and her claims are for small things (she will visit a doctor every time her nose drips and we have to cover the cost. She also even had a nose job and breast reduction that she somehow talked the insurance company into covering). Can we require that this particular employee pay more for her high claims? 

Sometimes it is difficult to balance the personal lives of your employees with their work lives. So often, the work lives and the employee lives are intertwined, especially when it comes to dealing with programs like health care programs and other benefits. The company is always impacted by employees that take unfair or unequal risks.

According to the federal act known as HIPAA, it is not legal to charge one employee a higher premium than another. HIPAA stands for Health Insurance Portability and Accountability and was put into place in order to protect employees that may have a history of having a serious medical condition from obtaining insurance. It does, however, sound like your employee may be taking advantage of her insurance policy in order to receive plastic surgery and perhaps some optional treatments. Unfortunately, you are legally bound to charge her the same amount as any other employee.

According to the regulations of HIPAA, you can exclude coverage for specific diseases (such as cancer), limit or do away with benefits for certain treatments or drugs, and limit or exclude benefits based on the classification of benefits. For example, if a particular benefit is experimental, then the HIPAA policy can be adjusted so that it does not cover the benefit. Beneficiaries of each health plan are also covered in a uniform manner to all other benefit recipients and beneficiaries.