What Do You Mean It's Not Covered: A Major Family Member Dispute

If you're about to have a baby, read your policy carefully and be extremely cautious about changing your insurance. The 1991 Florida appeals court decision -- Annemarie Harris v. Florida -- shows how much even people who are supposed to be familiar with the health insurance system can miscue. Annemarie Harris, an attorney employed as an assistant public defender by the Dade County Public Defender's Office, chose to enroll in one of the state-approved HMO plans for individual health insurance coverage shortly after she began her state employment. In December 1987 the contract between Harris's HMO and the state was terminated, and Harris was left with the option of selecting another HMO insurance plan or the self-insurance plan. To aid her in deciding which plan to apply for, Harris -- who was then three months' pregnant -- contacted Faith Quincoses, the administrative assistant in the public defender's office designated to advise employees of the benefits available to them under the various plans and to assist them in completing the paperwork necessary to secure such benefits. Quincoses supplied Harris with the names of several fellow employees whom she could contact regarding their experiences with the health insurance plans they had selected. Following her discussions, Harris elected individual coverage through the state group health self-insurance plan. In mid-April Harris again consulted Quincoses pertaining to the question of when she should convert from individual to family health insurance, so that her unborn child, who was due for delivery in June 1988, would be covered. Quincoses erroneously told Harris that in order for her child to be included under the state plan, she must prepare and submit the necessary paperwork within 30 days from the child's birth. Quincoses considered that as long as the employee notified the division and did the paperwork within 30 days after the child's birth, the child would be covered as a family member. Quincoses subsequently began work on the appropriate forms in order for Harris to complete her application for family coverage prior to June 1, the date scheduled for Harris' maternity leave. Before Harris signed the necessary papers, however, she experienced unexpected and severe complications with her pregnancy, resulting in an emergency premature birth in late April. Almost immediately following the delivery of the daughter, the child's condition worsened. She was transferred to another hospital with proper neonatal facilities. The infant remained in that hospital for approximately two months, incurring medical expenses of approximately $180,000. While the state health insurance plan covered Harris' expenses resulting from the birth, it refused to pay any of the child's expenses, on the ground that Harris had only individual -- not family -- coverage at the time of her daughter's birth. Although the paperwork, which Quincoses signed on behalf of Harris, was submitted on or about May 10, the State refused to provide the pertinent benefits available under family coverage, asserting that the child was not a named insured as of the date of her birth, and that once she became insured under the policy, her expenses related to a preexisting condition which was not covered under the policy.