I had this preexisting condition. (Funny word, “preexisting.” It seems to mean existence before existence. That doesn’t seem possible. When it comes to insurance, it really means an already-existing condition, but for some reason we use what should be the nonsensical “preexisting.”) It was a bad shoulder. I would have said that I had a dislocation problem, but that was not accurate. The bone did not come completely out of joint. I could pull it back into place with my free arm. I would have called it a partial dislocation, but the doctor who replaced my shoulder joint in the last year defined it as a subluxation.

The original subluxation had happened five years earlier, with the next one about six months later. When the bone slipped out of joint, it hurt like hell with residual pain for days afterward.  Over time, those disconcerting events happened with increasing frequency. It was time to get the joint repaired.

I did not have health insurance of my own. I was finishing what I hoped was my last year of schooling, and back then the only health insurance I was aware of was tied to employment. I had already accepted a job to start the following September. I would have health insurance through this employer, but I undertook the fun job of reading the policy and found the preexisting-conditions clause. The plan would not cover any health condition that existed when I first became insured.  Instead, the preexisting condition would only qualify for coverage two years down the road, assuming I was still in the same job. Waiting that long to have the shoulder surgery would not have been the end of the world. It was not as if I had cancer or imminent liver failure or was going blind. But it meant a couple more years of painful, partial dislocations and the awkward lifestyle changes that I had adopted to minimize them—not lifting my arm above my head, sleeping in ways so that rolling over would not cause the sublaxation, and so on. It also meant living with a constant level of pain that could be tolerated but still was not exactly fun.

The wife, however, had a job, and she had a health insurance benefit. I read that policy, too. It said that spouses of the insured were covered, and since she had been working for a while, the preexisting limitation did not preclude my shoulder surgery. I went to a famous shoulder surgeon who was ready to do my repair, but both he and the hospital wanted a notice from the insurance company that my treatment would be covered. We went to the benefits administrator at the wife’s work, who, to our surprise, said that the company’s insurance would not cover me for anything. “How can that be!?!” I exclaimed. I showed her the clause in the many-paged policy mandating coverage for “spouses” of the insured. The wife was the insured, we all agreed, and she and I were married, so I am the “spouse.” Ergo, I am covered. “No,” the administrator patiently explained, “‘spouse’ meant ‘wife.’” That is what it had always meant, the bureaucrat stated. We learned that only female spouses were considered beneficiaries under the plan because, apparently in those distant days, no man had ever sought to be covered before. The women utilizing the plan were either single, or if married, had husbands who had their own insurance or were too proud to seek spousal coverage.

I was flabbergasted, but not so much so that I could not pronounce the word “sue.” There are advantages to being a lawyer, even though back then I had little idea how to bring a suit. But the threat produced a further consideration by the wife’s employer and insurance carrier. With much grumbling, they decided that they would cover my shoulder surgery.

The wife left that job a little while later. After I had the surgery.

One thought on “For Preexisting Conditions, Spouse Means Wife

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