Health Insurance denies contraception

[Alas]

Hi, I 'm in the State of Maryland. I saw a post similar to my question, but I'd like to take it a step further about this health insurance Law:

http://mlis.state.md.us/cgi-win/web_statutes.exe
Article:Insurance
Section: 15-826

(Maryland was the First state to implement this)

I believe it basically says that employers and health insurance plans have to provide coverage for FDA approved contraception. Except if you work for a religious organization or the State.

How would you proceed if your insurance company, which is thru your employer told you that they would not cover your FDA approved method of contraception? The employer pays for this benefit, but the Insurance Company will Not.

I have condensed a two month's battle into this post, so I left out some details. Is it time for me to find a lawyer? Should I go through the insurance company's "appeal" process? It seems like i should go to a lawyer if they are breaking the law. It would be illegal, unfair and even tho this may not be intentional, it IS sexist, since birth control is a form of basic health care that only applies to women, since only women can get pregnant.

Any thoughts?

 

[cbg]

This may sound like a stupid question but I've worked for an insurance carrier and trust me, it isn't. If you've already gone through this and it's included in the condensation I apologize in advance.

Has it been brought to their attention that you are in a state that requires this coverage?

I ask because it happens sometimes that a particular benefit is covered only when it's in a state that requires it. All their literature says it's not covered because technically it's not a covered benefit; they cover it when the state says they have to but they don't consider it a covered benefit. The people you talk to on the phone look at the policy, they see "not a covered benefit" and they don't look any further.

ALthough it should be a given, it is sometimes necessary to get a supervisor on the phone and point out to them that you are in a state where this is mandated coverage. Be prepared with the statute numbers before you get on the phone. I promise you, they don't know off the top of their heads which states require this and which ones don't.

If you've already done this and are still having problems, your next step is to file a complaint with the state Insurance Commission. This will often take care of the matter for you and it doesn't cost you anything.

If that STILL doesn't do it, THEN you hire the lawyer.

 

[CIAA]

Well, I would have to do further research, and will when time permits. In the meantime, some obsevations:

This section does not say "employers" and health insurance plans....some other sections do refer to "employers" and one wonders why this one does not.
If it a "self-insured plan, it may not have to comply.

MD law may not apply if your employer's state of incorporation is not Maryland.

This apparently applies only where the plan provides for prescription drugs and, even then, one wonders if they could raise the question of "medical necessity", depending on the method.

Since this is going to be an ERISA plan, exempt from many state laws an Attorney is going to be hard to find in this fact situation, unless you want to pay the hourly fees. In any event, under Erisa you are generally required to exhaust all administrative appeals before you can sue (this part of the law is changing for claims filed after mid 2002 or 1/1/2003, depending on the plan).

In any event, if you want to crusade(and we applaude that), you should definitely appeal, requiring that they provide you with a clear explanation and the specific policy language on which they are relying, considering Md.'s Sec. 15-826. Please let us know and good luck.

 

[Alas]

cbg-thanks for your reply. I agree about your "stupid question" comment. I found out thru all of my research, how the law can be different in each state. Especially with us based in MD and talking to a lot of insurance offices in the District of Columbia. I've run into problems with that before, so I know better on that end.

However, in all of my communications, I specified Maryland, and also, in an email directly to the insurance company, i pasted section 15-826 for their reference. I basically told them that they needed to provide to me, in writing, why they are denying this benefit. Also, this was directed to a supervisor, a supervisor's supervisor.

I tried contacting some type of state insurance regulation type office, and the people on the phone were so clueless that I decided to try my luck elsewhere first. Maybe since I know more about what's going on, I will attempt to contact them again.

CIAA-thanks for your response also. I will need to see what ERISA is, I am not familiar.

I will keep you guys updated. Any comments or ideas are greatly appreciated. Oh and, yes, I will definitely fight this anyway I can

 

[cbg]

Again, I apologize if this is too simplistic. But don't just specify that you're in Maryland. Specify that you're in "Maryland, which by state mandate requires the payment of this benefit". Just specifying the state does nothing. They don't know what states require it without being told.

 

[tammy8]

I am not licensed in health/life insurance so this may be a stupid question to you health/life license holders but wouldnt' this be similar to some health ins companies simply not covering some drugs (ie would cover XXX drug but not XYZ drug)? Is it not up to the individual company to decide what drugs they do or do not cover? Like I said, I haven't a clue about health ins companies I just know of the several I have been insured with over the yrs, some covered BC pills and some didn't.

 

[Beth3]

Yes, it typically is up to the employer (via their health insurance carrier) to determine what will be covered under their group health insurance plan EXCEPT when there is a State or Federal manadate.

Those basically say that IF an employer chooses to offer group health, they the plan MUST cover [fill in the blank.] There are lots of mandates, particularly at the State level, which frequently has to do with how strong a lobby a particular special interest group has. Chriopractors have a strong lobby in my State, therefore my State has a mandate about including chiropractic coverage.

If an employer is self-insured, they can get out of some mandated coverages but not all.