What is the name of your state (only U.S. law)? Missouri
I need a hair prosthesis (wig) for a medical condition. The medical insurance plan Statement of Benefits provided by my employer includes this with other prosthetic devices, with only the following restrictions listed: "a prosthesis to replace hair lost as a result of a diagnosed Injury or Illness for which Benefits are payable under this Plan. Only one such prosthetic device will be Covered during the individual's lifetime and Benefits will be limited according to the Schedule of Medical Benefits" and "Prior Authorization required for items with a cost over $1,000" and "Hair prostheses (wigs and other hairpieces) over the lifetime Benefit and hairstyling." There is no mention of a maximum payment by the insurance company. Similar statement are found on other documents. However, when I call the insurance company, they say that they'll only cover up to $100. This is stated nowhere on any of the insurance handbooks or other papers provided by my employer. I called our benefits office; the lady I spoke with was also unaware of the $100 limit, but she later confirmed it with the insurance company and apologized for the error in our benefit materials. This is unsatisfactory to me. This omission made the Statement of Benefits and other medical plan documents provided by my employer false and misleading. Believing these documents to be true, I undertook measures I would not have otherwise. Because this omission is the fault of my employer, I think they should be responsible for the difference in the cost of the hair prosthesis. It will be $125. If I pay for the wig, can I take my employer to small claims court?
I need a hair prosthesis (wig) for a medical condition. The medical insurance plan Statement of Benefits provided by my employer includes this with other prosthetic devices, with only the following restrictions listed: "a prosthesis to replace hair lost as a result of a diagnosed Injury or Illness for which Benefits are payable under this Plan. Only one such prosthetic device will be Covered during the individual's lifetime and Benefits will be limited according to the Schedule of Medical Benefits" and "Prior Authorization required for items with a cost over $1,000" and "Hair prostheses (wigs and other hairpieces) over the lifetime Benefit and hairstyling." There is no mention of a maximum payment by the insurance company. Similar statement are found on other documents. However, when I call the insurance company, they say that they'll only cover up to $100. This is stated nowhere on any of the insurance handbooks or other papers provided by my employer. I called our benefits office; the lady I spoke with was also unaware of the $100 limit, but she later confirmed it with the insurance company and apologized for the error in our benefit materials. This is unsatisfactory to me. This omission made the Statement of Benefits and other medical plan documents provided by my employer false and misleading. Believing these documents to be true, I undertook measures I would not have otherwise. Because this omission is the fault of my employer, I think they should be responsible for the difference in the cost of the hair prosthesis. It will be $125. If I pay for the wig, can I take my employer to small claims court?
