group plan problems

[lredo]

What is the name of your state?
I live in GA

i signed up for insurance through my employer because the brouchure for the plan had good benefits. Now the insurance company won't pay the claims, stating i don't have any coverage. they said the brouchure/plan i signed up for is not the plan that i have. What can i do?

 

[cbg]

What does your employer say?

 

[lredo]

My employer gives me a number to call the insurance company!

 

[cbg]

That's not what I meant. Does your employer think you are signed up for the same benefits you signed up for? Or do they agree that you are signed up for the different plan? The answer makes a difference to what the problem is.

 

[lredo]

When I speak with my employer they first say call the district office. Then when I call there and speak to someone about it they tell me to call the insurance company. No one is giving me a straight answer! However when I go to our website (the companies) and look at the benefits the insurance plan is the same one I have, not the one the insurance company says I have!

 

[Beth3]

Iredo, what I suggest you do is to find out the name of the most senior person at your company who handles the benefits. Depending on the size of the company, that could be a Benefits Director or Manager, the Director or VP of Human Resources, the HR Manager, or even the Controller or CFO if you don't have a HR Department. What you need to do is to get past whatever clerk you've likely been talking to at the company who's just telling you to call the insurance company.

Anyway, find out the name of that person, call them and (nicely) tell them you urgently need help to straighten out your benefits situation and that you can't get a straight answer from anyone. Explain the problem and ask them to please look into it right away. It's quite possible that this is just an administrative error and somebody needs to look at your original enrollment paperwork and then contact the insurance company to rectify the situation.

If this doesn't work, then post back.

 

[lredo]

Beth,

I took your advice and sent a nice email to the company with copies to the area manager and district manager. Both the area and district manager came down to see me at work this past week and were throughly unhappy. They repeatedly told me that they are not insurance salesmen and that they can only tell me what they get from the insurance company. They said tell me who at the insurance company is giving you information and that they, my company, didn't change the policy they don't know anything about it. Then after they finished telling me how much they did not know; I was informed that by me being tardy on that day I would be terminated if I was ever late again. Now due to the medical problems I am having, I have been late twice because of the medicine I take. I informed them of this and they said it didn't matter, its not their concern. I also asked if anyone else would be getting the same treatment and they basically told me to mind my business. I think they are striking back at me because I have an opinion on the insurance. What am I supposed to do now?

 

[Beth3]

Just makes you want to beat your head against the wall, eh? Probably a simple problem with a simple solution if somebody would just take ownership of it and make a damn phone call.

Okay, Plan B. Call the insurance company back and ask to speak to the Manager of the Eligibilty Department. That is always a separate department from the claims group, as it helps guard against insurance fraud.

Among other things, Eligibilty handles the data entry of the newly eligibles from member companies. Presumably someone made a data entry mistake when your information was entered. Explain to the Eligibility Manager what's been going on and ask him/her to PLEASE pull your original information that was sent to the company and see if the situation can be straightened out.

As to the tardy problem, that really is a separate issue entirely. You may have become a bit "higher-profile" with your managers by raising the insurance issue but the bottom line is that most employers expect their employees to report to work on time.

 

[lredo]

I already spoke with the Eligibility manager and Department managers at the insurance company they stated the my company only has one policy and there are no errors. What now?

 

[cbg]

I think you may have to accept the possibility that you were looking at the wrong brochure.

 

[CIAA]

lredo.

Most all Employer sponsored benefit plans (except church and governmental) are subject to the Employee Retirement Income Security Act (ERISA) and the U.S. Department of Labor is responsible for oversight and enforcement. You can file a complaint with them and you should visit their website.

If you were enrolled for coverage and have had a claim denied ERISA requires that you be notified of your right to appeal, providing you with the name and address of the appeals section. All plans have a "Plan Administrator" and you can also WRITE them and ask about the appeals process, request any documents or records you may need, etc.

 

[lredo]

I never recieved anything that said I could appeal a claim I just recieved the denial. Where can I find more information about this I think that someone is ripping the employees off. I am not the only one with problems with the insurance. I am just the only one who says anything everyone else is afraid of loosing their job.

 

[Beth3]

If the employer is doing a "bait and switch" and/or you are being denied participation in a benefit plan, then the agency to complain to is the federal Department of Labor. 202-693-4650 www.dol.gov

 

[lkc15507]

Iredo:

I stongly agree with all the above, especially visiting the DOL website and / or contacting them. One other little thing, you state in your first post that the claims aren't covered under "the plan I have". Do you have a Summary Plan Description for the plan you do have? If not, request one now. This document will describe the benefits you do have and better educate you how to proceed. If they do not provide it to you timely, they can be fined by the DOL (if indeed an ERISA plan) if / when you file a complaint. Be sure your work behavior is exemplary and do not rely on ambiguous (to your employer) medical complaints to excuse potential work performance problems. (I'm not saying that this is what is happening--just don't give them the opportunity to make that claim.)

Best wishes,
lkc15507