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INDEPENDENT CONTRACTORS SHOULD EVALUATE BUSINESS CONTRACTS CLOSELY

By Business Protection Bulletin

In the U.S. today, one result of corporate downsizing, is that there are many independent contractors in the marketplace. After picking themselves up off the ground and dusting off their overcoats, many former members of “Corporate America” have struck out on their own. With that shift comes freedom, but also new anxieties, and, perhaps, new found insurance issues. One such issue is that of the business contract.

Detailed business contracts with explicit and often confusing legalese have become a common document for independent contractors to evaluate. The contractor must often either acquiesce to unfavorable terms dictated by corporate legal departments, or forego the contract. Below are some suggestions on how to resolve the contractual dilemma of whether or not to sign on the dotted line.

  1. Speak with your attorney. Although it might not be practical to have a lawyer review every contract offered to you prior to signing, it is usually better than the alternative. It is probably better to limit the legal review to advice rather than negotiations, though there are some contract negotiations for which it would be appropriate to have a lawyer or a representative agent present. However, for a typical small contract where you are being asked to sign boilerplate language, it might send the wrong signal to your client.
  2. Consult with our insurance agents. Contracts generally contain clauses that might impact your insurance coverage. They might require either indemnification, certificates of insurance, and/or additional insured status for the client (on your Professional Liability, General Liability, and/or Workers Compensation policies to name a few). Each of these provisions could impact your insurance as follows
    • Indemnifications – a typical indemnification provision looks something like this: “Consultant (or contractor or subcontractor)” shall indemnify, defend, and hold harmless Client against any and all claims, liabilities, losses and expenses arising out of or in connection with Consultant’s performance of the Services hereunder … ” This is considered a unilateral indemnification. It is the least favorable to the contractor and you would do well to request a mutual indemnification provision where both parties agree to indemnify the other for liability arising out of their respective negligence. The worst that can happen is your suggestion being rejected.
    • Certificates of Insurance – it is quite common for certificates of insurance to be requested by your client. This documentation of your insured status serves as a confirmation to the existence of your coverage. With the request often comes a provision for notice to the client if coverage lapses. Check with your insurer to see if he will agree to this provision. Many insurers don’t have a mechanism for notifying certificate holders of the imminent lapse of a policy and will not agree to, though some will compromise with less onerous “endeavor to” wording, such as, “we will endeavor to notify you within 30 days of the termination of the policy … ”
    • Additional Insured – additional insured status for your client can provide an acknowledgement of the liability that you have taken on in the contract and effectively transfers the liability to the insurer, subject to all the terms and conditions of the policy. Check with our agents to see if there is any cost for adding on additional insureds. If there is any charge at all, it is usually nominal.
  3. Review your Liability insurance contracts for exclusions. Many liability contracts exclude contractual liability, with the exception of liability that would attach to you in the absence of the contract. An example of a contractual liability that might be excluded would be a penalty for failing to meet a deadline. On the other hand, indemnifications are often considered a liability you would incur regardless of the contractual provision. For instance, if a suit is brought against you and your client, and it is clear that it was your work that was being questioned, your insurer might offer to defend your client to avoid the potential for a hostile witness.
  4. Create your own engagement letter. It is always a good idea to spell out your thoughts regarding payment terms, work expectations, limitations of liability, and other aspects of the work you will perform. In lieu of or in addition to a client’s contract, this letter could help to prevent future misunderstandings.

UNDERSTAND THE RIGHTS AND RESPONSIBILITIES OF TEEN EMPLOYEES IN THE WORKPLACE

By Business Protection Bulletin

Every year, millions of teenagers join the workplace for the first time. A first job can be a positive experience for many, teaching them discipline and responsibility in addition to giving them some extra money. However, some teens find themselves working in hostile environments. Their supervisors might treat them unfairly because of their sex or race, harass them, hassle them about reasonable work accommodations, and retaliate against them if they complain to upper management about these conditions. Employers who tolerate mistreatment of employees, including teens, could find themselves in trouble with the law.

The federal Equal Employment Opportunity Commission described several examples of harassment of teens on its YouthAtWork.com Web site:

  • In Pennsylvania, a 19 year-old shift supervisor at a Mexican restaurant sexually assaulted a 16 year-old female employee. His manager accused the girl of making it up, but after the supervisor confessed to the police, the EEOC sued the restaurant, which paid $150,000 in restitution to the employee and a fine to the EEOC.
  • A store manager at a fast food place in Kansas harassed and sexually assaulted a 14 year-old girl. He eventually went to prison, but because the company had permitted him to harass at least four female employees, it paid restitution, wrote letters of apology, and was required to implement mandatory sexual harassment training for employees.
  • Several women, both teen-aged and older, were sexually harassed by a store manager at a California bagel shop. Their complaints to management did not improve the situation, and eventually some of them quit. The EEOC sued the shop, the offending manager lost his job, and the owners of the shop paid a steep penalty.

The EEOC’s Web site lists several rights and responsibilities of teen-aged workers, including:

  • The right to work free of discrimination.
  • The responsibility to treat other employees without discrimination.
  • The right to work free of harassment.
  • The right to complain about job discrimination without punishment, and the responsibility to inform management of discrimination.
  • The right and responsibility to request workplace changes for the worker’s religion or disability.

The right to keep medical information private. To avoid harassment claims from any employees, young or old, employers should:

  • Adopt, promote, and enforce a formal policy against sexual harassment.
  • Take reports of harassment seriously. Investigate all reports and take appropriate action, if required.
  • Emphasize to supervisors and managers that they are not to retaliate against employees who complain of harassment.
  • Provide training for managers on how to recognize sexual harassment and how to receive complaints.
  • Train new employees on how to recognize harassment and how to make complaints.

Employers should also carry Employment Practices Liability insurance (EPLI) to protect themselves against the financial consequences of claims that do occur. EPLI policies cover the employer’s liability for discrimination, wrongful termination of employment, sexual harassment, rights violations, and other harmful acts committed by company managers. One of our professional insurance agents can give advice on the different policies available and their cost.

Employers have a responsibility to provide a safe working environment for all employees, but that responsibility is magnified when it comes to teenage employees. Keeping your workplace harassment-free will ensure a happy, productive workforce and keep your attention where it should be — on growing your business.

CONSIDER THE POSITIVES AND NEGATIVES OF EMPLOYEE LEASING

By Business Protection Bulletin

Employee leasing firms earned $68 billion in gross revenues in 2008, according to the National Association of Professional Employer Organizations (NAPEO). Their clients, primarily small businesses with fewer than 20 employees, outsource to leasing firms the responsibilities for payroll administration, employee benefits, Workers Compensation claim management, human resource management, and related operations. Businesses trying to reduce costs and focus on growth might find employee leasing to be an attractive option. It is an option, however, that comes with advantages and disadvantages for both employer and employee.

The NAPEO cites a number of benefits from employee leasing. The benefits for employers include:

  • Access to professionals with expertise in human resources, payroll, risk management, and employee benefits.
  • Assistance with labor law compliance.
  • Professional claim management.
  • Reduced and controlled administrative costs.
  • Professionally written employee handbooks, policies, and procedures.
  • Relief from some employment-related liabilities.
  • Reduced Workers Compensation costs resulting from improved workplace safety.

Employees might also benefit from leasing in several ways.

  • Access to benefits that might not have otherwise been available, such as 401(k) plans, cafeteria plans, insurance, and credit union membership.
  • Timely and accurate paychecks.
  • Protection under federal labor laws.
  • Improved communication among and between employees.
  • Employees who move from one leasing client to another do not lose eligibility for benefits.
  • Efficient and timely claim processing.
  • Assistance with employment-related issues.

Employee leasing carries some risks. A poorly managed leasing firm might mishandle payroll and benefits or could go out of business, leaving the client with its obligations. The employer might also be legally liable for the actions or inactions of the leasing firm. For example, if the leasing firm fails to comply with regulations, it could be the employer who bears ultimate responsibility. Also, the employer is ceding control of its workforce to a third party who might or might not do things the way the employer would. Employee relations could suffer during the transition to leasing.

From the employees’ standpoint, the employer would have to fire them and the leasing firm would have to re-hire them. Also, there is no guarantee that the leasing firm’s benefits will be as good as those the employer offered. Some employers have also used leasing as a means to avoid dealing with unions, though federal rules might limit their ability to do this.

Employers who decide to lease their employees should evaluate the leasing firms it considers carefully. The financial stability of the firm and of the insurance companies providing its benefits are a major consideration, as the failure of either could leave the employer with unfunded obligations. The firm’s experience in the employer’s industry, track record of success, and safety record are also important. Another consideration is the range of benefits the firm offers; a plan that does not meet the employer’s needs will not be worth the expense of hiring the leasing firm.

Employee leasing is a big step and not one to be taken lightly. Employers must weigh the upsides and downsides of leasing and make decisions that are best for their employees and their businesses.

HOLD HARMLESS AGREEMENTS AND CONTRACTUAL LIABILITY INSURANCE HELP MANAGE RISK

By Construction Insurance Bulletin

Lawsuits are a common occurrence in our litigious society. An effective way to limit your liability is to specify your responsibility in a contractual relationship. Risk can be transferred contractually by including “hold harmless” clauses in agreements.

In a hold harmless agreement, one party agrees to protect or “indemnify” another from claims brought by a third party for financial loss or damage. A good example is a general contractor who hires a subcontractor to complete a job for a third party. To protect himself, the general contractor may require the subcontractor to sign a hold harmless agreement. The agreement would indemnify the general contractor if any problems arose from the subcontractor’s work.

Read before You Sign on the Dotted Line

In a hold harmless agreement, the indemnitor (the party that has assumed the liability) is responsible for all financial loss. Some hold harmless clauses are very broad. Surprisingly, they may include liability even if the indemnified company was solely responsible for the damage. On the other hand, a Contractual Liability insurance policy can protect the indemnitor, but might not cover all aspects of liability.

In our example above, the hold harmless agreement gives the general contractor the right to collect for damages paid to the third party to the extent enforceable under the law. However, the indemnified party should exercise caution. The ability to uphold indemnification agreements differs by state, because state laws vary as to what risks may be transferred. Also, some courts have ruled indemnification clauses unenforceable if they were not clear and precise.

Protect Your Assets

With a General Liability policy, Contractual Liability insurance is provided automatically. The coverage is created to pay to a third party damages assumed as part of an “insured contract.” However, the definition of an insured contract is limited, and coverage is written as an exception to an exclusion. That means the policy excludes coverage except for specific circumstances. Additional policies, such as Professional Liability insurance, might be required to cover exposures that are not covered under General Liability policies.

Usually, General Liability insurance covers only bodily injury or property damage. But once again, these are subject to exclusions, conditions, and limitations, and the injury or damage must have occurred after entering into the contract.

Furthermore, the liability must be one that would be imposed without the contract or one that is assumed in a hold harmless or indemnity agreement that falls within the definition of insured contract under the policy. General Liability policies do not cover breach of contract.

Before signing any contract, it is wise to talk to an attorney, so that you do not assume liability that is not covered under your General Liability insurance policy. Take time to read your insurance policy endorsements carefully, and don’t be afraid to ask our insurance agents to explain anything you do not understand. We will help you to determine the types of coverages your business needs to protect your assets.

HOLD HARMLESS AGREEMENTS AND CONTRACTUAL LIABILITY INSURANCE HELP MANAGE RISK

By Construction Insurance Bulletin

Lawsuits are a common occurrence in our litigious society. An effective way to limit your liability is to specify your responsibility in a contractual relationship. Risk can be transferred contractually by including “hold harmless” clauses in agreements.

In a hold harmless agreement, one party agrees to protect or “indemnify” another from claims brought by a third party for financial loss or damage. A good example is a general contractor who hires a subcontractor to complete a job for a third party. To protect himself, the general contractor may require the subcontractor to sign a hold harmless agreement. The agreement would indemnify the general contractor if any problems arose from the subcontractor’s work.

Read before You Sign on the Dotted Line

In a hold harmless agreement, the indemnitor (the party that has assumed the liability) is responsible for all financial loss. Some hold harmless clauses are very broad. Surprisingly, they may include liability even if the indemnified company was solely responsible for the damage. On the other hand, a Contractual Liability insurance policy can protect the indemnitor, but might not cover all aspects of liability.

In our example above, the hold harmless agreement gives the general contractor the right to collect for damages paid to the third party to the extent enforceable under the law. However, the indemnified party should exercise caution. The ability to uphold indemnification agreements differs by state, because state laws vary as to what risks may be transferred. Also, some courts have ruled indemnification clauses unenforceable if they were not clear and precise.

Protect Your Assets

With a General Liability policy, Contractual Liability insurance is provided automatically. The coverage is created to pay to a third party damages assumed as part of an “insured contract.” However, the definition of an insured contract is limited, and coverage is written as an exception to an exclusion. That means the policy excludes coverage except for specific circumstances. Additional policies, such as Professional Liability insurance, might be required to cover exposures that are not covered under General Liability policies.

Usually, General Liability insurance covers only bodily injury or property damage. But once again, these are subject to exclusions, conditions, and limitations, and the injury or damage must have occurred after entering into the contract.

Furthermore, the liability must be one that would be imposed without the contract or one that is assumed in a hold harmless or indemnity agreement that falls within the definition of insured contract under the policy. General Liability policies do not cover breach of contract.

Before signing any contract, it is wise to talk to an attorney, so that you do not assume liability that is not covered under your General Liability insurance policy. Take time to read your insurance policy endorsements carefully, and don’t be afraid to ask our insurance agents to explain anything you do not understand. We will help you to determine the types of coverages your business needs to protect your assets.

FOLLOW BASIC SAFETY RULES TO PREVENT ACCIDENTS AT THE WORKPLACE

By Workplace Safety

A discussion regarding workplace safety doesn’t have to strike an anxiety chord. Although it is important for employers to formulate safety programs and oversee their enforcement, it isn’t as difficult a task as it might seem. Many workplace safety rules are not that different from the safety rules you learned as a child.

Basic housekeeping should be a top priority in preventing workplace accidents. Not only is a clean work environment far more inviting to work in, but it also allows you to be more productive than a messy one. Most importantly, keeping the workplace clean means keeping it safe. When housekeeping chores like clearing away oil, water, and refuse are handled in a timely fashion, you keep the workplace both pleasant to work in and accident-free. Another way to prevent accidents is to keep aisles and exits clear of obstacles at all times. During work hours exit doors should remain unlocked. Keeping up with equipment maintenance is another rule that needs to be observed to remain accident-free. All dangerous or unsafe equipment should be tagged and taken off the job floor until corrective maintenance has been completed.

Remember when you were in school, and the teacher told you to walk, and not run? This is another basic rule for the workplace as well. Running unnecessarily sets the stage for possible injuries from falls. Unless the situation warrants it, you should always avoid running in the workplace.

There is tremendous potential for workplace damage and injury where chemicals are concerned. Hazardous materials should be kept in appropriate containers; and each container must be accurately labeled to indicate what’s inside and any hazards associated with their use. Only employees who have completed special training should handle hazardous chemicals.

Flammable liquids are similar to hazardous chemicals in their potential for causing harm. All flammable liquids must be put in safety containers with appropriate labels. If a safety container becomes damaged, take it out of service as soon as possible and replace it with a new container. When not in use, containers holding flammable liquids should be kept in a proper storage area.

Fires don’t wait around until you are ready to deal with them; they just keep on burning until they rage out of control. Having a fire extinguisher available when a fire starts can make the difference between little damage and catastrophic harm. Always be certain that fire extinguishers are in good working order, and that they are accessible at all times, in any situation where they might be needed.

Finally, employees should never hesitate to report unsafe acts or conditions to their department manager as soon as possible. It is crucial to be observant in identifying any problem areas that could cause an accident. Your safety and the safety of your co-workers depend on everyone pulling together on a daily basis with safe behavior and practices at work.

IN HAZARDOUS DRIVING CONDITIONS, EXERCISE EXTRA CAUTION

By Workplace Safety

Everyone knows that winter driving can be hazardous. In California and the southern states, you might face torrential rains and flooding conditions that make driving demanding and dangerous. Thick fog can appear seemingly out of nowhere, when cool air meets the warmer ground. As a driver, you might even have an occasional bout of hail, sleet, or snow to handle. If you live in a northern state, you can almost certainly look forward to times of intense cold, sleet, freezing rain, and lots of snow, all contributing to dangerous road conditions.

No matter where you live, you should be prepared for winter driving and the conditions that it can create in your area. Here are a few driving tips that will help you to arrive alive, even during difficult driving conditions.

In the case of extreme fog, it is best not to drive at all but if you have to, slow down. Driving too fast or following other vehicles too closely causes most of the accidents that occur in foggy conditions. Make sure to drive with your low beams on, and stay within the limits of your vision. If the fog gets too dense, pull completely off the road, stop, and turn on your hazard lights.

Even a simple rain shower can cause problems on the road. If it starts raining while you are driving, increase your braking distance and lower your speed on curves and during turns. If it begins to rain more heavily, slow down even more to avoid hydroplaning, which is when your tires ride on a layer of water and not on the pavement.

If snow has fallen before you begin driving, remove all snow and ice from your vehicle and especially your windows before you head out onto the roadway. Also, make certain that your vehicle is in good working condition and that you have plenty of windshield washer fluid.

If you will be driving in an area known for snowy conditions, consider using snow tires or chains for extra traction. Test your braking ability by gently applying pressure to the brake pedal and releasing. If the road is icy or frozen, reduce your speed accordingly.

Shaded areas, bridges, and overpasses are often icier than other places on the road. Be careful and be prepared. Make sure that your cell phone is fully charged in case you need to make an emergency call. Consider carrying food and a winter survival kit in your car:

  • Ice scraper
  • Small Snow Shovel
  • Tire Chains
  • Small bag of abrasive materials (sand, salt or kitty litter)
  • Cloth or roll of material
  • Jumper cables
  • Blanket
  • Snow brush
  • Warning devices (flares or triangles)
  • Traction mats
  • Flashlight

Finally, check local weather reports before traveling into a winter storm area. If possible, enjoy the winter wonderland from the comfort of your home. If you must drive, follow these tips to prevent the mishaps of winter driving. Arrive alive.

KNOW YOUR RIGHTS, AND REFUSE DANGEROUS WORK

By Workplace Safety

If you simply refused to perform your duties on the jobsite, what would happen? More than likely, your boss would tell you to hit the road. However, there are a few rare cases when you not only have the right to refuse to work, but you’re actually protected by the Occupational Safety and Health Act (OSHA) to do so.

Refusing unsafe work. You have the right to refuse to perform unsafe work if you believe that you are at risk of being injured or killed. However, as with any other work issue, it’s important to follow the proper procedures. According to OSHA, “If a health or safety hazard at your workplace puts you in imminent danger of death or a serious injury including situations immediately dangerous to life and health, tell your supervisor immediately. Ask that the condition be corrected and that no workers be exposed to the danger until it is eliminated or controlled.” In other words, the first step you should take is to ask your supervisor to correct the dangerous situation. If your employer fails to fix the problem, call the nearest OSHA office immediately. Give them all the specific details of your situation. If you report the problem as one of “imminent danger,” OSHA will give it the highest priority and send an inspector to your jobsite within one day.

What if your employer threatens to fire you? Of course, if you refuse to work, your employer might decide to fire or discipline you before the OSHA inspector arrives on the jobsite. Fortunately, OSHA covers workers who are disciplined for refusing to perform unsafe work. According to OSHA law, “OSHA can protect you if you are discharged or otherwise disciplined for refusing to perform a task that would expose you to imminent danger of death or serious injury, providing you have sought and been unable to obtain a remedy from your supervisor and there is insufficient time to have the condition corrected through filing a complaint with OSHA.”

If you refuse the dangerous work on behalf of your fellow workers, you might also be protected by the National Labor Relations Board (NLRB). OSHA and the NLRB often work jointly on refusal-to-work cases involving dangerous situations. If you are punished for refusing to perform an unsafe job, contact one of these agencies as soon as possible.

Danger must be imminent. However, before you refuse to work, you must be certain that the work poses imminent danger to you and your co-workers. In other words, you have to be able to prove that the problem could cause immediate and serious harm to you or other employees. For example, let’s say you’ve been working with a damaged piece of machinery for three weeks. Although you haven’t gotten injured, you have asked your supervisor multiple times to repair the machine. One day, you get tired of asking and refuse to work.

Unfortunately, in this case, OSHA might not be able to protect you. After all, you’ve been working with this piece of machinery for many weeks without getting hurt. This will make it difficult for you to prove that danger is imminent. However, if you had refused to work as soon as the machine was damaged, it might be a different story.

On the other hand, let’s say someone spills hazardous chemicals in your work area. You report the spill to your supervisor immediately and ask him to call in professionals to clean it up. He says he’ll get to it later and tells you to get back to work. Because this puts you and your co-workers in immediate, serious danger, you can refuse to work near the hazardous chemicals. In this scenario, OSHA would likely protect you if your employer tried to punish you for not working.

Team up with other workers. If you feel that you and your fellow workers face imminent danger on the jobsite, don’t go at it alone. Try to get your co-workers on board and approach your supervisor together. OSHA points out that acting as a group is safer when it comes to refusing unsafe work.

UNDERSTAND GUIDELINES OF FMLA INTERMITTENT LEAVE, AND MANAGE YOUR EMPLOYEES BETTER

By Employment Resources

The Family and Medical Leave Act (FMLA) allows employees to take job-protected unpaid leave for certain specified reasons: To care for their own or a family member’s serious health condition; to care for a newborn or newly adopted child; or in connection with military family leave, in the event of a qualifying exigency or a serious injury or illness of a covered military member.

Since its inception, one of the most vexing aspects of FMLA administration for employers has been intermittent leave — those FMLA provisions that allow employees to take leave in separate blocks of time, or on a reduced schedule, due to a single qualifying reason. Intermittent/reduced schedule leave can be taken when medically necessary (either the employee’s own or a family member’s serious health condition) or in connection with military family leave. However, if the reason for the leave request is to care for a newborn or newly adopted child, intermittent/reduced schedule FMLA leave is allowed only if the employer consents to it. An example of this would be if the employer agrees to a part-time work schedule after a child’s birth/adoption.

For intermittent leave triggered by a serious health condition, circumstances must be such that the medical need can best be accommodated through an intermittent or reduced schedule. This includes situations where the seriously ill individual requires treatment by a health care provider periodically, rather than for one continuous period of time. Examples include leave taken on an occasional basis for medical appointments; leave taken for several days at a time over a period of months for chemotherapy; and leave taken by a pregnant employee for prenatal exams or for severe morning sickness. An employee recovering from a serious illness who is not yet strong enough to work full time would be an example of a situation appropriate for a reduced schedule FMLA leave.

Regulations state that employees needing leave on an intermittent or reduced schedule basis for planned medical treatment must make a reasonable effort to schedule the treatment so as not to disrupt the employer’s operations unduly. Employees must give 30-days notice for intermittent leave that is foreseeable at least that amount of time in advance, and as much notice as possible for leave that is not so foreseeable. Employers are to account for intermittent or reduced schedule leave using a time increment no greater than the shortest period of time it uses to account for other forms of leave, provided this is not greater than one hour and further provided that this increment cannot be greater than the amount of leave actually taken. However, if an employee on intermittent/reduced schedule FMLA leave cannot, due to the nature of the job, begin work mid-shift — such as an employee who works aboard a train or airplane during scheduled runs — the entire period that the employee is forced to be absent counts against the employee’s FMLA entitlement.

Also to ease the potential disruptive nature of intermittent FMLA leave, an employer can choose to transfer an employee taking intermittent/reduced schedule leave to a position with equivalent pay and benefits if the need for FMLA leave is foreseeable, the employee is qualified for the transferred-to position, and the position accommodates the recurring leave periods better than the employee’s ongoing position. Transfers made for this reason are to be temporary.

Employers that suspect the FMLA intermittent leave allowance is being abused have some tools in the regulations that they can use in an attempt to manage this. For example, employers can require a medical certification for any type of FMLA leave, and also a recertification, to make sure that the leave request is justified. The right to request recertification can be particularly helpful in the case of intermittent leave, which can span a long period of time. If the employer observes a pattern of intermittent leave taking that appears suspicious — such as scheduling the leave increments adjacent to weekends or holidays — requiring recertification can help to establish whether such a leave schedule is necessary.

Other provisions in the regulations can be used to minimize the disruptive potential of intermittent leave. For example, holding leave-requesting employees to the full extent of permitted notice requirements can aid in work schedule planning. Also, as noted above, an employer can transfer an employee temporarily to a position that would be less disrupted by the employee’s intermittent absences. Though this might not result in less leave being taken, it can help operations to run more smoothly.

UNDERTAKE DEPENDENT ELIGIBILITY AUDIT TO CONTAIN HEALTH PLAN COSTS

By Employment Resources

As employers search for ways to contain employee benefit plan costs, many are undertaking dependent eligibility audits. The logic and potential cost savings is compelling. Why pay for something — in this case, coverage for someone not entitled to it under the terms of a benefit plan — when you don’t have to?

According to the results of client dependent eligibility audits conducted by HRAdvance, a third-party provider of audit services, the percentage of ineligible dependents detected in such audits ranges from 7% to 19%. And, with each employee dependent covered under a health plan running about $3,400 annually (with this amount varying considerably company to company, according to figures from Aon Consulting), the potential cost savings can be dramatic, even for a small company. Aon cites the potential return on investment from dependent eligibility audits as high as 40 to 1. Savings should be considerable, when you consider that each removed ineligible dependent represents dollars saved year after year.

Though the cost savings are compelling, they’re not the only reason to conduct a dependent eligibility audit. ERISA mandates that benefit plans be maintained for the “exclusive benefit” of employees, and employers as plan fiduciaries are required to operate plans accordingly. Arguably, covering ineligible individuals, which can create additional plan costs for all employees, runs afoul of these requirements.

The purpose of a dependent eligibility audit is to verify that individuals listed by employees as eligible for coverage under the plan (primarily spouses and dependent children) indeed meet the plan requirements for eligibility. A simple employee certification or affidavit of dependent eligibility does not provide proof of this, and therefore an audit requires employees to submit documents that substantiate eligibility. An audit will be a significant undertaking.

Consider that you will need to:

  • Review health plan documents (and the documents for any other plans for which the audit is being conducted) to determine the definitions for all possible eligible dependents.
  • Determine the documentation you will require for substantiating eligibility. For example, in the case of a spouse, this might be not only a marriage license or certificate, but also a recently filed joint income tax return to show that the marriage continues to the present day.
  • Establish a time line for informing employees about the audit and a deadline for submitting the required documentation, and develop communications materials accordingly.
  • Determine the process by which employees can submit their documentation, and set up a mechanism to receive materials.
  • Review submitted documentation to determine whether they meet the requirements for establishing eligibility, and establish a notification and grace period process for employees who fail to submit materials properly and/or on time. Inform employees of the audit results.
  • Since these audits generate a large amount of paper, arrange for secure storage and/or disposal of the materials employees have submitted.
  • Since the audit will likely generate questions from employees, a knowledgeable person or persons must be assigned to field employee inquiries.

Some companies choose to outsource dependent eligibility audits instead of conducting them in-house. Audit service providers cite the potential cost savings that can be achieved and the amount of work involved in a thorough, well-designed audit to argue that contracting for such services delivers a good return on investment. If you decide to use an outside resource, you’ll likely have a choice of vendors. With more and more employers conducting dependent eligibility audits, an industry specializing in this particular employee benefit plan service has developed.

Other design considerations can impact the workload an audit generates. For example, in order to make the process more manageable, some companies audit only a particular dependent group, or a single company division or location at a time, instead of requiring all employees enrolling dependents to submit dependent documentation. If you’re considering homing in on particular dependent groups, data from HRAdvance’s client audit shows the distribution of ineligible dependents to be 43% children under age 19, 29% children over age 19, and 28% spouses. Another consideration that can impact the manageability of the audit is whether to conduct it retrospectively (and try to recover claims that shouldn’t have been paid) or on a forward-looking basis only. Many employers also choose to precede the audit with an amnesty period during which employees can voluntarily remove dependents from the plan with no penalty.

Since most companies traditionally have run on an honor system when covering dependents — basically taking an employee’s word for it that those dependents enrolled for coverage indeed meet a definition of eligible dependent — advance communications to alert employees of the audit, and the reasons for it, are critical to employee cooperation and, ultimately, how successful the audit will be. Use all available media, and stress that removing individuals who are not eligible for coverage will benefit not only the company, but all employees who are paying to have themselves, and family members, covered by the plan.