Health Insurance Coverage for Separated Spouse?

Make and bring in copies of those tax returns, the title on the house, marriage certificate. Do not use the word "separated." "We are married. We live apart because that's what works for us, have for 10 years. We have no intention of divorcing."

My guess is that you will be required to prove that you are married and in the meantime, the insurance company saves a little money by denying a bunch of shit, allowing them to invest that money for longer before they pay you.

Appeal. Be polite. Assume "innocent mistake" or "misunderstanding" for the time being. Put everything in writing. Ask if there is a North Carolina team or a special team for handling errors/complaints or some other special somebody who should be looking at your case. I paid insurance claims for five years. Every single state has "state exceptions" and where you have some oddball thing going on in a particular state, you see more errors. For now, assume that is the issue. And remind them that they paid claims previously, therefore you should be covered. That isn't a hard and fast rule, but it can influence the situation and that's the position you should (politely) take.

It took a lot of phone calls and persistence and some documentation, but my insurance benefits were finally restored and were retroactive to the date they denied me. Now I just have to get all my providers to refile their claims for that period of time!

Considering you have to be legally separated a year in North Carolina before you can get divorced, I don't know what you mean-but for the record my daughter lives in NC and her husband whom she has been separated from for two years but is NOT divorced from is able to use his (military) insurance. This may or may not apply to you but I am throwing it out there. As a matter of fact the reason they aren't divorced is he wants her to have insurance as she has an ongoing medical issue.

Insurance companies are notorious for disregarding state-specific insurance laws. I don't know if that is the situation you are in. But the company is likely making a big mistake, and it will be sorted out quickly and easily, or you might have to push and push for it to be resolved to your satisfaction. Just don't rely on the HR person to sort it out for you - it's possible that they will just pass on incorrect information from the insurer, and they are not practitioners of insurance law to begin with. Your next step after HR would definitely be with an attorney, and it should be an attorney experienced in health insurance law in North Carolina. Also worth your time to put in a call to the state insurance commissioner.

If what is going on now still doesn't work after much work, I don't suppose you could "reconcile" and maintain your place as a second vacation home and perhaps somewhere you go to recover (for weeks on end?) after medical treatments.

If this plan is a self-funded plan, the employer has a lot more leeway on deciding what constitutes physically separated. Employers can exclude physically separated spouses from coverage--does the SPD for the health plan address that? Do you know if it's a self-funded or fully insured plan? If it's a self-funded plan, the state's insurance commissioner will not be able to do anything for you, as self-funded plans are under ERISA, a federal law. Bottom line, check the plan documents.