Self-Insured Companies... do they right their own rules?

[kristalynn]

What is the name of your state? WI

My sister was receiving inpatient treatment at Rogers Memorial Hospital in Oconomowoc, WI for depression/suicide/anorexia (the works!). The insurance company said they would not pay anymore, but her Dr's said she was not well enough to leave and advised my mother to keep her there and appeal the decision .. which she did. The appeal was denied after 1 week and now my mother was left with $12k bill for that 1 week of care before we received the denial of the appeal. She had no choice but to bring her home being a single mom trying to raise a trouble teenage daughter. My sister has already been readmitted to another hospital for care as Rogers will not take her back until the bill is paid in full... so she clearly was not better in the first place. My mom went to the WI Insurance commissioner who agreed that the insurance should pay and wrote a letter to ins co UHC. Apparently he cannot help as the insurance is through father's employer FedEx which is self-insured so the commissioner has no authority over them. UHC is only the administrator. What can we do and where do we start. Please help! Thank you so much for your time and assistance in this matter... we really need it. My mother does not have $500/month to put towards medical bills.. but she was too afraid for her life to bring her home based on the Dr's recommendations.

[cbg]

In many cases, unless a state or Federal law specifically spells out something that a self-insured policy must cover, yes, they get to decide what is and is not covered.

If the employer is the owner of the policy, your parent's (there is no "we" - you have no standing with your father's employer) recourse is to appeal through them. If neither the insurance commissioner nor the administrator can order them to pay (and from your description I agree that they cannot) her recourse is limited.

What does the policy say with regards to payment for this condition? Does it spell out a limit?

[kristalynn]

I can check with my mom about the policy, but I don't think it's possible that they had reached any limit described in the policy because she went back in for the same thing a couple months later (obviously released too soon the last time)... and they've paid for that with no problem at all.
They decided she was 'OK' to go home because the Dr said she had not threatened suicide in 3 days. Though the Dr said that she was still a threat to herself, the insurance company disagreed.
Thank you for your help!

[cbg]

The specifics, whether it be limits on days or dollars or something else, will have a great deal to do with any possibility of a successful appeal. For example, if it says they will only pay for ten days, nothing in the law is going to make them pay eleven (unless a specific law specifically says they must pay for fifteen, or something on that line). If the policy says they will only pay $2500, they have no legal obligation to pay the 2501st dollar. If the policy says they will only pay for treatment that occurs on the Thursday of a full moon, they have no obligation to pay for treatment that occurs on the Tuesday of the first quarter.

But if the terms are ambiguous, you have a much better chance of prevailing.

Note that I am using the term "you" generically. Again, you have no legal standing to appeal; only your father (and possibly your mother, if the employer wants to be nice) does, since it is through his employer.

[kristalynn]

I talked to my mom and she said there is no limit at all (neither days or $) in the policy. They just decided (against Dr recommendation) that she was no longer a threat to herself. What would you suggest she do... does she need to contact a lawyer? My parents are divorced and my father is not even helping her pay for the medical bills so him going to FedEx is highly unlikely.
Thank you again for your time and much appreciated advice!

[cbg]

Since I haven't read the policy I cannot guarantee anything. It certainly can't hurt to show the policy to a lawyer, preferably one who is familiar with insurance law, and see what he thinks. I am not in a position to tell you if there is any chance whatsoever of your prevailing since I can't read the policy - days and dollars are not the only possible exclusions or limits, just the most common ones.

Most people have the mistaken idea that an insurance carrier is bound to pay for anything that the doctor says is medically necessary. That is not how it works. IF there is something in there that gives them the right to make this exclusion, it's not likely that the law will force them to pay, doctor recommendation or not. It's all going to depend on the exact wording of the policy.

[ecmst12]

The policy probably has an appeals procedure, that is a good place to start. If your mom can contact the benefits department at Fedex, they may be able to help, but I would start the appeals procedure first. Customer service should be able to tell her the steps she needs to take.

[kristalynn]

Thank you both... we will start there.