Employer not funding approved medical claims for self-insured plan.

[eaglesfly00]

What is the name of your state (only U.S. law)? Indiana
My medical plan at work is a self-insured plan. I make a contribution from my check each pay period for my health insurance premium. I have claims for my son's hospital stay over 6 months ago. When I called the TPA they told me the claims have been approved and are waiting for over 2 months to be funded by my employer. What can I do to get my claims paid? The hospital keeps calling and saying they will turn me over for collections if they don't get paid.

 

[cbg]

When you asked your employer about this, what did they say?

 

[eaglesfly00]

Money is tight right now.

 

[Beth3]

If you want to pursue this, then contact the federal Department of Labor and file a complaint. Your employer is legally obligated to fund the plan to cover legitimate claims that are presented for payment.

 

[momm2500]

you need to file a complaint with the department of labor. the company is in violation. the dol will come into your employer and investigate. the fact that you are paying premiums is a big thing here. if the plan was fully self-funded and you did not pay premiums, it is a little harder to get the dol involved.

and do not worry about reporting them. when you contact the dol, you can advise them that you want to remane anonimous so the employer does not know it is you reporting them. if you have co-workers who are also in the same boat, advise them to do the same.

one of my clients is now in big trouble with the DOL since this is what they have been doing for years. it had gotten so bad that we (the tpa) found out that the company was using 401k money to pay for the health insurance bills. it was horrible and i felt bad when i talked to the employees and doctors everyday questioning when their bills were going to get paid.

 

[cbg]

Would you answer me a question, please, Mom?

Beth told him three days ago to contact the DOL. So why are you suddenly showing up all of a sudden to give him the same information he's already got?

 

[momm2500]

does it really matter to you? maybe i do not spend all day on this site like you do

 

[cbg]

Actually, I spend a very small percentage of my day on this site.

And no, it doesn't really matter to me. I just wondered why you so frequently answer questions several days after the fact with the same answers that have already been given, instead of seeing that the poster has been answered and moving on to the next.

But if you don't have an answer to that, it's no never mind to me.

 

[eaglesfly00]

I just want to make sure I understand what I need to do. There is a federal DOL and a state DOL. If I understand the above posting, I should file my complaint with the Federal DOL? And are you sure they will not give out my name?

And what happens if the company closes in the next few days or weeks and the bills have still not been paid?

 

[pattytx]

Such plans are governed by ERISA, so it's the Federal DOL. They may or may not mention your name, but if they do and if you are fired because of your complaint, there are whistleblower laws to protect you.

The other, you'll have to ask them.