Reinterpetation of benefits

[turok100]

What is the name of your state? OK

I have a claims for a Surgical Assistant RN which is not being paid under a self funded plan admistered by a third party. They denied the claims stating 'non physicans' were not covered. BUT this did not go in to affect until May 2004 (middle of year - their new guidelines). Prior to May 2004 they did pay for the same RN services. They stated they 'reinterpeted' the benefits and its no longer covered. They did NOT send out any documentation stating they would be changing guidlines. Since it was paid in 2003 and the same service was used in 2004 (2004 SPD stated no changes in benefits) both I and the provider thought she was covered. I have already appealed once - but they state they did not 'reduce' benefits - if I had used an MD it would have been covered. And just cause they paid for it earlier they dont now... Is this right???

 

[ALawyer]

"Self-funded plan administered by a third-party" suggests this is an employer plan that would be covered by ERISA.

You have rights to internal appeal and to sue. A "reinterpretation" without notice -- particularly after having paid ther benefits in a prior year -- suggests that they should have paid this one too.

This is one to take to your HR person -- it is unfair (given prior payment history) to deny if BOTH there was a real need for the service and the cost for an MD would have been identical or higher -- but ERISA plans are not necessarily fair and suing can put you in a bad light with your employer.