Employer Self Funded Group Insurance Plan

[kareesh]

Greeting,

In a nut shell
An insurance coverage for about $50000 is denied under pre existing exclusions by the insurance company.

I did not receive any plan documents or summary plan descriptions on the same from my employer.

My employer is a foreign corporation who does business in USA.Does ERISA laws exclude such foreign corporates from not following USA laws ? Is there any section which says any foreign corporate can claim that these laws are not applicable for them.However they have issued Statement of Rights stating ERISA and HIPAA.

Do i need an attorney for this case ? if yes in what specilization i should find an attorney.

Pls advice

I am stuck here .

 

[cbg]

1.) Are YOU in the US?

2.) Did you have previous EMPLOYER SPONSORED insurance before becoming covered on this plan? If so, when did it end?

3.) How long have you been covered on your current plan?

4.) Did you, at any time, contact the insurance company and ask them whether the procedure would be covered?

 

[kareesh]

1) I am in USA currently for about 8 months.The suregry happened 6 months ago.

2)I am working for the same employer XYZ for the past 4 years in different countries based on my project.Had group medical coverage in every single country i was in for a project.I am not sure whether my previous plans are employer sponsorde but all plans were provided or recommended by employer.The plan ended the day before i stepped into US and got enrolled into this new medical plan.In short i had a continous coverage for medical plan.

3)Current plan i am covered from Feb 2004 (say 8 months) when i stepped into USA to work for the same employer XYZ in a different client site.

4)Before the surgery i contacted the insurance company to verify benefits at the same time hospital also contacted the insurance company to verify benefits.at that point the pre existing exclusion was not discussed either to me or the hospital.

 

[cbg]

Okay, in view of your answers I have another question. Prior to February 2004 did you have previous insurance IN THE UNITED STATES and if so, between what dates?

 

[kareesh]

I came into USA only in Feb 2004(my first visit).I did not have any insurance in US before.

 

[cbg]

Not all insurance coverage is "creditable" coverage with regards to HIPAA,and coverage in another country is not creditable coverage. If you have only been in the US for 8 months, then it is legal for the insurance company to consider a condition pre-existing. No US laws have been broken by the insurance carrier. HIPAA does not apply in your case and ERISA does not require the insurance carrier to pay all submitted charges.

You do have the right to have a copy of the SPD and you may certainly ask your employer and/or the insurance company for a copy. But unless your state law specifically says otherwise (and while I have not studied the laws of all 50 states I don't know of any that do say otherwise) failure on the part of your employer to give you a copy of the SPD does not obligate the insurance carrier to pay for bills that would not normally be covered. (BTW, someone is going to get on my back for answering your question without pointing out that you did not give us your state, despite the fact that it is explicitly asked for.)

You can try calling the state insurance commission and ask them whether your employer's failure to give you a copy of the SPD entitles you to demand payment of the charges from your employer. However, that's your only chance and it's a VERY much a long shot. My memory is that the employer has seven months to give you a copy of the SPD - from what you say you had the surgery when you'd been there for two months. So at that time it was legal for the employer to have NOT given you the SPD, and I very much doubt that they will be held liable for charges you incurred at at time when they were in compliance with the law and that you incurred without asking about any pre-ex clauses in the coverage. You do have some personal responsibility - it is NOT the responsibility of the insurance company or the employer to hold your hand through the process and to guess whether or not pre-ex may apply. I'm sorry to be so blunt, but that is nonetheless the case.

 

[kareesh]

Illinois is my state that i currently live in.

Thanks for your answer.It is not blunt but it is real.I completely understand that the insurance carrier is not responsible for the case but being a self funded health plan is my employer not responsible for explaining the pre ex clauses ?

It might sound logical, how does a foreign national is expected to know abt ERISA and HIPAA and other related rules of this country ?
When i doubt my condition is not pre ex as per controversial opinions from several doctors in several countries how do i demand which is pre ex and which is not ?

 

[cbg]

Kareesh, let's be realistic. Are you seriously going to tell me that you would have put off having needed medical treatment for ten to twelve months if you had been told about the pre-existing clauses?

If you have been treated for a condition within the look-back period (generally twelve months) the condition is pre-existing. In your case, that means (assuming that the 12 months applies) that if you had been treated at any time for this condition between February 2003 and February 2004 it is pre-existing.

 

[kareesh]

Seriously CBG, i would have put of my surgery and relied on pain management if i had known about the pre ex clauses as i know i cannot manage to pay $50000 as i had to return back to my home country shortly.

 

[okamsrazor]

It might sound logical, how does a foreign national is expected to know abt ERISA and HIPAA and other related rules of this country ?

Well, you could have studied our laws before you came into the USA to try to steal someones job.