Insurance co. denying coverage for treatment clearly covered on Summary Plan Document

[Weasley1]

What is the name of your state? NV

Briefly situation is as follows:
Self insured plan between employer and health insurance company.
The only plan document outlining benefits and exclusions they provide is the Summary Plan Document. (SPD)
SPD CLEARLY states that IVF is a covered expense. No ambiguity.
However, Insurance co, states IVF is NOT covered based on their records and refuse to pay. (We both have the same current plan info dated Jan 1 2002 but they say 2 different things!)

When I attempted to get a copy of the agreement/contract between employer and the ins. co to see exactly what the policy included and excluded, I was told that the SPD was the only document they supply to employees and that the contract didn't give any information on benefits anyway!

My understanding is that the SPD consitutes evidence of coverage in this situation.
If they continue to deny that IVF treatment is covered and the SPD clearly states that covered expenses include "charges made for or in connection with In-vitro fertilization" do they have a good faith obligation to cover these expenses?

 

[ALawyer]

Historically ambiguity ihas been resolved in favor of the beneficiary or policyholder.

As this involves an employment benefit, ERISA likely covers it, and ERISA really does not permit punitive damage bad faith claims.

 

[Weasley1]

Thank you for your reply. I don't want punitive damages, nor am I interested in getting confrontational.
I just want them to cover my treatment! I have had a number of other people read the SPD in question and they also conclude that basedon the terms spelled out it appers they cover IVF.

If they keep insisting they will not cover my treatment...what do I do?

 

[CIAA]

Weasley1,

ALawyer is correct, even under ERISA ambiguities must be construed in your favor. The problem her is: are we dealing with an ambiguity, a printing error, or an administrative error because the plan has changed and you were not delivered the correct one?

While their probably should be a GroupPolicy, the regs. say you can rely on the SPD; you just need to make sure you have the right one.

The U.S. Dept. of Labor has regulatory and enforcement authority over employer ERISA plans. You can learn more by visiting their web site. They also have a national HELP line that you can call and they can direct you. Call 1-866-4-USA-DOL and explain your problem and that you want to make sure you have the right SPD, and if you do , you want your claim considered. They should be able to help you. Let us know

 

[lkc15507]

I am confused. "health insurance company" -- do you mean the "stop-loss / reinsurance carrier"? If so, their reimbursement to the self-funded plan has no bearing on the coverage provided by the employer group (self-funded) plan to you as the insured member (at least if your self funded plan wishes to stay out of court).

Next, are we sure that this is an ERISA plan? Do you work for a state / city / government employer? If this is a self funded ERISA plan, it is regulated by the Department of Labor which may provide you with some recourse. (Non-ERISA plans will be regulated by your state's department of insurance.)

But, most importantly, back to the first paragraph, if by "health insurance company", you mean the self-funded plan's stop-loss carrier, make your first appeal / complaint to the plan! The employer self-funed plan! You will probably be making that appeal to the plan administrator or TPA (third party administrator). If that plan covers IVF, then they must cover it regardless of their reimbursement by stop - loss! i. e. the stop-loss plan coverage to the "plan" may not agree with the "plan's" coverage to you.

Next caution, read the plan document, or SPD very carefully, be sure what heading you are reading under. Then, do not rely on your own interpretation alone, call their customer service line (which should be maintained by the TPA) and ask specific questions about coverage. Get Names and Take Notes!

Most plans whether fully insured or self insured provide an appeals process which should be outlined in your plan document. If the plan doc is not available to you now, request one from the HR dept at your place of employment. If they cannot / will not make one available request it from them in writing. If all else fails, determine for sure whether ERISA or Non-ERISA plan and then contact appropriate governing body. But, again, either of those agencies will want to know if you have followed the appeals processes available to you at the 'plan' level.

(FYI==I am a registered nurse case manager currently working for a third party administrator of self-funded group heal insurance plans.)

Let us know how it turns out!

 

[lkc15507]

Ok, I'm on a roll. Clarifications: some self-funded plans still administer their own plan. If so, all of the above still apply, but delete where I refer to a TPA. Then, be aware of confidentiality laws and laws that prohibit the 'personnel' / 'human resourses' department from administering things like 'payroll'. i.e. the same folks in charge of cutting your paycheck shouldn't have a clue what your medical problems are.--Keeps them from firing you because you cost too much in medical expenses. Also, above when i asked state / city / government, I should have included school and church. (FYI many hospitals fall into the 'church' category too.)

ALawyer et al are correct. If push comes to shove, courts almost always side with the insured when there is any ambiguity in the language of the doc (but, this is very subjective). HOWEVER, if you are well informed, well armed (leave emotion out), stick to sound scientific evidence-based medicine, seek the advice of medical professionals to help write appeals and follow the appeals process, I bet you will win.

The last thing I will address is the "good faith obligation". Again, experience only from the insurance standpoint, not legal, SPD vs. plan doc. The plan doc will be the basis of the "plan's" point of view regardless of what a summary may present. Although they (the plan) may provide an SPD or a schedule of benefits to outline basic benefits, those aids will be subject to what is in the master doc. This doc will usually include a time frame for changes to be made to the doc itself. The plan can change a benefit and make it retro active for a period of time. The kicker is, is the plan making the change because they know of an existing claim? If so, that is usually a no-no.

In a nut-shell, it is the responsibility of the insured member to determine if they have benefits. That is why I suggest --call, Take Names and Take Notes. Reading a plan doc is wide open for interpretation. It may favor your view, it may not.

Misrepresentation is misrepresentation.