Adding a grandchild in your custody to your health plan

It is the law that solves a very common problem: a grandparent or an aunt raises a minor by court order, or cares for an adult relative declared incapacitated, and the insurer refuses to put them on the family policy because they are not a child of the insured. This Act removes that refusal: the insurer must accept the inclusion. What it does not remove is the cost — premiums, deductible and co-payment are still paid by the principal insured.

The Act covers two situations and both require a formal decision, not a verbal arrangement. The first: minors “whose custody or guardianship has been granted to grandparents or other participating relatives.” The second: adults “who have been declared incapacitated and whose guardianship has been adjudicated.” In both cases the person holding custody or guardianship must be “the beneficiary or principal insured of that policy.” The Act uses the words “granted” and “adjudicated”: it describes custody and guardianship that have been awarded, not de facto situations, and we will not stretch the text beyond that.

• That it be a minor whose custody or guardianship has been granted to grandparents or another relative, or an adult declared incapacitated whose guardianship has been adjudicated.Verified against the official source
• That the person granted custody or guardianship be the beneficiary or principal insured of the family policy.Verified against the official source

Information pending verification.

1. 1

   Step 1: The insurer must accept

   Article 1 is the whole Act in one sentence. It provides “that health insurance plan insurers in the Commonwealth of Puerto Rico accept, in a family policy, the inclusion as beneficiaries of minors whose custody or guardianship has been granted to grandparents or other participating relatives and of adults who have been declared incapacitated and whose guardianship has been adjudicated, when the person granted custody or guardianship is the beneficiary or principal insured of that policy.” It is not the insurer’s option: it is a duty.

2. 2

   Step 2: It is not only for grandparents

   The Act’s title speaks of grandparents and so many people assume it is limited to them. The text is broader: it says “grandparents or other participating relatives,” and Article 2 repeats it when speaking of the principal insured, “whether the grandparents or any other relative.” An aunt, an uncle or an older sibling with granted custody falls under the same rule.

3. 3

   Step 3: It also covers the adult declared incapacitated

   It is the half of the Act almost never mentioned. The duty to accept applies equally to “adults who have been declared incapacitated and whose guardianship has been adjudicated.” If you care for an adult relative under adjudicated guardianship and you are the principal insured, the insurer has the same duty to accept them onto the family policy.

4. 4

   Step 4: Accepting does not mean free

   We put this beside the right so the expectation is correct. Article 2 says: “The principal insured, whether the grandparents or any other relative, shall pay the corresponding deductible, co-payment and premiums, according to the type of coverage selected.” The Act requires the insurer to accept the inclusion; it does not forbid charging what corresponds for that coverage.

5. 5

   Step 5: If they say no: the Insurance Commissioner

   Article 3 closes with the sentence that tells you whom to turn to: “The Insurance Commissioner shall ensure insurers’ faithful compliance with this Act’s provisions.” That is the office that oversees insurers as to this duty. We did not read the Insurance Code’s complaint procedure, so we publish no deadlines or form.

6. 6

   Step 6: Since when it applies, and to which policies

   Article 4 sets two things: “This Act shall take effect eleven (11) months after its approval and shall apply to every health insurance policy sold or renewed eleven (11) months after its approval.” The Act is from 2007, so that moment passed long ago: in practice it reaches every policy sold or renewed since. If your policy renews yearly, it is already within it.

7. 7

   Step 7: The Act asks for a formal decision, not a family arrangement

   It is the right’s boundary and we would rather say it before you are told at the counter. The text speaks of custody or guardianship “granted” and guardianship “adjudicated,” and of an adult “declared incapacitated.” Those words describe an awarded determination, not a de facto situation however long-standing. The Act does not say which document proves it or before whom, and we do not invent it.

The step is taken with your insurer, which has the duty to accept the inclusion in the family policy. If it refuses, the Act designates the Insurance Commissioner of Puerto Rico to ensure insurers’ faithful compliance. The implementing regulation was for the Secretary of the Treasury together with the Director of the Health Insurance Administration and the Insurance Commissioner; we did not read it and publish none of its content.

• Believing it applies only to grandparents: the text says “grandparents or other participating relatives” and “any other relative.”
• Thinking it covers only minors: it also covers adults declared incapacitated whose guardianship has been adjudicated.
• Expecting it to be free: the principal insured pays deductible, co-payment and premiums according to the coverage selected.
• Trying it with informal custody: the Act speaks of custody or guardianship granted and guardianship adjudicated.
• Accepting the insurer’s refusal without more: the Insurance Commissioner oversees insurers’ compliance with this Act.
• Assuming your policy is too old to be covered: the Act applies to every policy sold or renewed since it took effect in 2008.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov