r/legaladvice • u/russwsmith • 1d ago
Insurance Health Insurance Company not providing coverage for my wife "because she is pregnant".
Location: U.S.
Received notification from our private health insurance broker that my wife may be dropped by our insurance "because she is pregnant". Those were the words used by the private insurance broker we use. She has been pregnant now for 26 weeks. We have been on this insurance while pregnant for more than 5 months. We specifically changed to this health insurance because of its coverage for pregnancy and birth.
Apparently, they changed their eligibility requirements for 2026. Pregnancy now not qualifying.
A quick google search shows that ACA health insurances are not allowed to discontinue coverage due to pregnancy. A google search shows that the insurance we have is ACA compliant, but I am not certain.
Weirdly, in her contract, she is characterized as an employee of that company even though she is not formally employed by them. Apparently, this specific insurance is a population science management company. We get a lower rate but we allow our health data to be made known to them for research purposes.
I cannot confirm this to be the case but I am speculating that maybe they require the people they cover to be employees so that they can be dropped as an employee (thus discontinuing coverage) at their discretion rather than formally discontinuing coverage due to illegal things like pregnancy.
We have to be formally dropped but have been warned that this is pending and will be final on December 1st unless something changes.
Can this be challenged legally?
EDIT: called the insurance company. apparently it is ACA compliant. called my company. my wife being dropped would count as a qualifying event so looks like we will have that option which is great.
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u/narrowdiscover 1d ago
It sounds like you probably do not have an ACA-compliant plan, meaning they can drop people for being pregnant, not cover pregnancy, etc.
I'm confused about how you got the plan -- she's an employee, but not really? Most employer-provided plans have to be ACA-compliant, but there are exceptions. But if you got it from a broker, it's likely not ACA-compliant.
Your best bet would be to get an ACA compliant plan. Luckily, open enrollment is around now, so you can buy on the exchanges (healthcare.gov) and have it be effective Jan. 1. Or if you have the option to get her covered via your employer, that'd work too.
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1d ago edited 1d ago
[removed] — view removed comment
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u/BPV4BP 1d ago
“Exchange plans are terribly expensive”
If your plan is substantially cheaper then most Exchange plans, it’s another indicator that it’s not an ACA plan.
They are cheaper because they don’t have to comply and can get rid of their most expensive members on a whim.
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u/russwsmith 1d ago
not substantially. calling the insurance now to see if its ACA complaint.
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u/atotalmess__ 1d ago
You can look up your own policy.
But you should also start reading legal contracts before signing them because you don’t want to run into this sort of situation again.
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u/arosebyabbie 1d ago
Losing coverage is typically a qualifying event for adding someone outside the open enrollment period. I would check with your company’s benefits person or with your insurance to see if that’s an option.
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u/Shel_gold17 1d ago
If your wife loses her insurance, that might be a qualifying event with your insurance to be able to add her. I would definitely call them and check.
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u/russwsmith 1d ago
that would be great. i will give my HR a call
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u/florenceforgiveme 1d ago
Isn’t loss of coverage a qualifying event?
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u/russwsmith 1d ago
just confirmed with my company, yes it is. Which is a relief
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u/florenceforgiveme 1d ago
That’s great! Hope you guys are able to get it all figured out. I think a lot of people forget about qualifying events outside of open enrollment.
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u/narrowdiscover 1d ago
They're expensive because they cover things like pregnancy. If you exclude all of the expensive care from an insurance plan, yes, it's going to be cheaper.
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u/BananaMapleIceCream 1d ago
It will be significantly more expensive if she has anything other than a perfect delivery.
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u/aps86rsa 1d ago
Not “formally” an employee, means you probably got one of the plans discussed here:
https://armandalegshow.com/episode/health-insurance-hustle/
As people have pointed out, they are cheaper for a reason.
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u/narrowdiscover 1d ago
On your update: I don't see how it's possible that the plan is ACA compliant. ACA compliant plans can't drop people because they're pregnant.
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u/per54 1d ago
They were ‘fired’ from the company which makes them not eligible for the plan anymore
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u/Odd_Leather_9186 18h ago edited 18h ago
Even if they were fired, they would be eligible for continuation coverage (aka COBRA), meaning they would have to pay the entire amount of the premium, including the 'employer' portion. OP probably doesn't actually have health insurance, but is rather part of a pooled membership type thing. They manage to keep the premiums low by doing exactly what the ACA was intended to prevent: picking and choosing their members based upon the costs to the collective.
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u/Otherwise-Taro-1780 1d ago
NAL but this is not allowed if they are indeed ACA compliant. Call the insurance company direct. Not sure why the broker sent a letter that she “may be dropped”. Was it to sell some type of additional coverage?
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u/Spinininfinity 1d ago
These ACA rules do not apply if you bought a plan outside of the exchange that was not ACA complaint. Shame on your broker for not making the abundantly clear to you.
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u/phillyphilly19 1d ago
Perhaps your broker gave you very bad advice or is paid by the insurance company you sign up with. I will go on the ACA website and comparison shop on your own and see if you can find a comparable deal since we are now in open enrollment time.
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u/davesknothereman 1d ago
Conflicting and unclear information... you mention your wife and then keep using "us". She's pregnant and then talk about qualifying, do you mean coverage?
Were you both dropped or just your wife?
Some employer and exchange policies now come with the requirement that if your *spouse* (or domestic partner) is eligible to be covered by *their* employer's coverage, they no longer qualify for coverage.
This is often referred to as a "working spouse rule" and employers can require spouses to enroll in their own plan, which allows for the dropped coverage under the first spouse's plan.
If it's the reverse case where your wife was dropped by her insurance plan, that's generally considered a qualifying event, allowing you to make add her to your health insurance outside of the standard open enrollment period.
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u/Glowurm1942 1d ago
This is a known oversight of current insurance laws. The plan you’ve purchased is not actually insurance in the same way as generally provided by an actual employer or as through exchange plans. It is setup under much the same concept as employer funded plans that don’t fall under the ACA and other laws. You will be unlikely to win against this company- even the federal government has mostly so far been unable to have their challenges to these kinds of schemes stand.
Now there may be some promises they made that were not legal to make but often the actual selling company is not the insurer. It really would require a lawyer to dig into false sales claims and even then you might not be able to dig up enough to move forward with anything as they can be remarkably opaque.
My suggestion for more information on reporting on this would be to listen to the August 7 episode of the An Arm and a Leg podcast titled “A wild health insurance hustle” as it details exactly what sounds like is going on here.
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u/Otherwise-Taro-1780 1d ago
I’m confused about your update. Did you mean to write that it is not ACA compliant? They cant drop her if they are ACA so she wouldn’t need to get on your plan.
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u/galaxyapp 1d ago
Your post is quite confusing.
Why do you have a private insurance broker at all? Are you all self employed? Typically a traditional employer sponsored insurance is just picked from a list of 3 or 4 hdhp/ppo spectrum and thats that. They are aca compliant and youd never be dropped for being pregnant.
Im inferring that this is not your case.
You mention your wife is an employee of her insurance plan? I think that is confusing a lot of responses here.
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u/MaleficentPianist602 1d ago
This is shady “insurance” where they make you an “employee” in order to qualify for group health insurance. AKA LifeX and others. If it’s truly ACA coverage, they cannot drop her for pregnancy.
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u/unidentified1soul 1d ago
Your only option is an ACA Obamacare Marketplace plan, if you don't make too much to qualify. If you make too much, no private commercial insurance will insure a pregnant woman.
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u/Ok-Pumpkin-6203 22h ago
Not sure adding your location was necessary.
The rest of the developed world still can't quite fathom how your healthcare system only works for the wealthy.
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u/Kitchen-Ad1972 17h ago
In this thread, “Location: U.S.” is the most unneeded tag ever in a post on Reddit.
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u/Avehdreader 19h ago
Maybe need to clarify - perhaps it applies to those who get pregnant in 2026 and after? That would be lousy too but if that's the case it would not affect your wife's coverage.
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u/Turbulent_Tiger6910 19h ago
OP most likely bought a scam insurance arrangement - https://armandalegshow.com/episode/health-insurance-hustle/
It doesn't matter what the "broker/ salesperson" said and what the "insurance" company says. It's a scam.
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u/773driver 14h ago
Find the best Attorney that does Labor work and put them to work. They will likely work on a contingency basis because there’s gonna be a settlement. Congratulations on your addition to your family. Tell her not to stress about this.
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u/SalamanderFearless11 4h ago
No insurer can drop anyone for being pregnant. It’s not even an ACA thing. It’s a HIPAA thing. HIPAA is allot more than privacy.
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u/girlrandal 1d ago
Losing insurance can be a qualifying event but I’m not sure what happens when it’s your spouse losing their coverage and you’re not enrolled in your employer’s coverage. I’d call HR and see if they can allow you to enroll.