John Doe, )
Plaintiff/ First Petitioner, )
v. ) HEALTH INSURANCE ORDER
Mary Doe, ) DR-6
Defendant/Second Petitioner. )
__________________________________________ )
The Van Wert County Child Support Enforcement Agency shall hereinafter be referred to as C.S.E.A. in this Order.
There are four alternative orders hereinafter recited. The orders are either ALTERNATIVE I, II, III or IV and each order has a box next to it. One of the boxes next to the four alternative orders has an “X” in it which designated the appropriate order. The Court hereby orders the alternative designated by the marked box into execution and the parties thereby effected are thereby bound .
ALTERNATIVE I: ORDER TO THE OBLIGOR
The Court finds that ________________________, the Obligor, is under a child support order and that the Obligor is ordered to obtain health insurance coverage through ________________________ and that health insurance is not available at a more reasonable cost through a group health insurance or health care policy, contract or plan available to the Obligee.
IT IS THEREFORE ORDERED, ADJUDGED AND DECREED THAT:
1. No later than thirty (30) days after the issuance of this order, the Obligor obtain health insurance overage for the following children, to wit: _______________________________________________ and to furnish written proof to the C.S.E.A. that the required health insurance coverage has been obtained.
2. The Obligor shall supply the Obligee with information regarding the benefits, limitations and exclusions of the health insurance coverage, copies of any benefits under the health insurance coverage and a copy of cards necessary to obtain services and file claims, and
3. The Obligor submit a copy of this order to the insurer at the time application is made to enroll the children and that the Obligor, not later than thirty (30) days after the issuance of this order furnish written proof to the C.S.E.A. that the foregoing orders have been complied with.
82 ALTERNATIVE II: ORDER TO THE OBLIGEE
The Court finds that ________________________, the Obligee, is under a child support order and that the Obligee is ordered to obtain health insurance coverage through ________________________ and that health insurance is not available at a more reasonable cost through a group health insurance or health care policy, contract or plan available to the Obligor.
IT IS THEREFORE ORDERED , ADJUDGED AND DECREED THAT:
1. No later than thirty (30) days after the issuance of this order, the Obligee obtain health insurance overage for the following children, to wit: ____________
_________________________________________________________________________ and to furnish written proof to the C.S.E.A. that the required health insurance coverage has been obtained.
2. The Obligee submit a copy of this order to the insurer at the time application is made to enroll the children and that the Obligee, not later than thirty (30) days after the issuance of this order furnish written proof to the C.S.E.A. that the foregoing orders have been complied with.
ALTERNATIVE III: ORDER TO BOTH OBLIGEE AND OBLIGOR, DUAL COVERAGE
The Court finds that health insurance coverage is available a reasonable cost to the Obligor ________________________ and to the Obligor through
________________________ and that dual coverage by both parents would provide for coordination of medical benefits without duplication of coverage.
IT IS NOW THEREFORE ORDERED, ADJUDGED AND DECREED THAT:
1. No later than thirty (30) days after the issuance of this order, that both the Obligor and the Obligee obtain health insurance overage for the following children, to wit:
__________________________________________________________
_________________________________________________________________________ and to furnish written proof to the C.S.E.A. that the required health insurance coverage has been obtained.
2. The Obligor and Obligee submit a copy of this order to the insurer at the time application is made to enroll the children and that the Obligor and Obligee, not later than thirty (30) days after the issuance of this order furnish written proof to the C.S.E.A. that the foregoing orders have been complied with.
IT IS FURTHER ORDERED, ADJUDGED AND DECREED that the Obligor or Obligee ordered to obtain health insurance coverage for the child(ren) must continue coverage beyond the age of 18 as long as the child remains in any recognized and accredited high school on a full time basis. The coverage will continue during seasonal vacation periods until the order terminates.
IT IS FURTHER ORDERED, ADJUDGED AND DECREED that both Obligor and Obligee, within 30 days of the issuance of this order, designate the child(ren) who are the subject of the child support order as covered dependents on any health insurance plan for which they contract.
ALTERNATIVE IV: ORDER ON BOTH OBLIGOR AND OBLIGEE, NO COVERAGE
The court finds that neither Obligor or Obligee has health insurance coverage available at the time of this order.
IT IS NOW THEREFORE ORDERED, ADJUDGED AND DECREED THAT:
1. At such time as health insurance is available to either the Obligor or the Obligee at a reasonable cost, that they shall obtain such health insurance coverage for the following children, to wit:
_________________________________
_________________________________________________________________________
2. The Obligor and Obligee submit a copy of this order to the insurer at the time application is made to enroll the children and that the Obligor and Obligee, not later than thirty (30) days after the issuance of this order furnish written proof to the C.S.E.A. that the foregoing orders have been complied with. IN ADDITION TO THE TERMS AND CONDITIONS SPECIFIED IN THE ABOVE MARKED
ALTERNATIVE, THE FOLLOWING ORDERS SHALL BE APPLICABLE .
IT IS FURTHER ORDERED, ADJUDGED AND DECREED THAT both the Obligor and Obligee, within thirty (30) days of the issuance of this order, designate the children who are the subject of the child support order as covered dependents on any health insurance plan for which they contract.
IT IS FURTHER ORDERED, ADJUDGED AND DECREED THAT THE
OBLIGOR OBLIGEE BOTH OBLIGOR AND OBLIGEE
be responsible for unreimbursed health care costs to include, but are not limited to co-payments and deductible costs as follows. to wit: ______________
_________________________________________________________________________ ________________________________________________________________________.
Reimbursement for out-of-pocket hospital, medical, dental, optical and prescription expenses and any other health care expense paid for the children shall be made to:
_______________________________________________________.
The insurer that provides the health insurance coverage for the children may continue making payments for hospital, medical, dental, optical and prescrip-tion services or any other health care expense directly to any health care provider in accordance with the applicable health insurance or health care policy, contract or plan.
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NOTICE TO OBLIGOR, OBLIGEE, EMPLOYER, INSURANCE COMPANY