What Do You Mean It's Not Covered: A Difficult Case of Dependent Child Coverage

The complicated and controversial 1994 Texas Supreme Court decision -- Edwadine Forbau v. Aetna Life Insurance Co. -- considered the limits that health carriers will sometimes try to place on their policies. In March 1983, fourteen-year old Amy Miller suffered serious, permanent, and disabling injuries as a result of a motor vehicle accident. She was left a permanently disabled quadriplegic, in need of twenty-four hour supervision. At the time, Amy's father, Mike Miller, was insured under an Aetna group insurance policy issued to Affiliated Foods, Inc., a cooperative of grocery stores of which his employer was a member. Miller's premiums and those of his dependents, including Amy's, were paid by his employer. Miller was eligible as an "individual" under the plan, defined as an "employee of any store owner who is a participant under this plan;" Amy was eligible for dependent coverage as an "individual's unmarried child under nineteen years of age." After Amy's accident, Aetna paid her medical expenses as incurred until April 1985, when Affiliated terminated the group contract with Aetna. Aetna continued to pay benefits until May 1986, under the policy's one-year extension of benefits clause. After that date, Edwadine Forbau, Amy Miller's mother, submitted claims to Safeco Life Insurance Company as Aetna's successor insurer for Affiliated's members. A dispute eventually arose between Forbau and Safeco, which resulted in a lawsuit and settlement.