Kaiser changed reason for denial?

[arkera]

What is the name of your state (only U.S. law)? CA

I'm fighting with Kaiser to cover a service that they DO offer, but typically stonewall unless their hand is forced by the Department of Managed Health Care (DMHC). So I've filed my grievance and appeal, and they sent me a final denial letter, saying that there were "alternative treatments available". Fine. So I filed my complaint with the DMHC last week, but this morning I got another letter from Kaiser saying that they've revised their reason for denying me, and now it's because it's "not medically necessary."

I know it's still a denial, and that my next step was to file with the DMHC anyway, but I addressed their original denial reason in my DMHC complaint, and now I need to write some kind of follow-up for this new denial reason. I was poking around the internet, and I found this:

http://reinsurance.staufferlaw.com/2012/06/erisa-plan-cannot-change-reason-for-denial-of-claim/

On appeal, the Tenth Circuit notes that a plan administrator is required by statute to provide a claimant with the specific reasons for a claim denial along with a citation to the specific plan provision. As a result, federal courts will consider only “those rationales that were specifically articulated in the administrative record as the basis for denying a claim.” The Tenth Circuit states: “The specific reasons and specific provisions supporting Defendant’s broad coverage argument have changed, and we will not permit Defendant to sandbag Plaintiff with its after-the-fact interpretation of an entirely different section of the Plan.”

A Plan administrator will not be given interminable opportunities to search for alternative grounds to deny benefits. Having rejected the sole basis upon which the administrator grounded its denial of Plaintiff’s plausible claim for benefits, the Court would not permit the administrator to rely on new grounds for denial in this litigation or in further administrative proceedings.

Of course this is ERISA and I'm dealing with the DMHC, but is there anything I can use in my follow-up letter to address this switcharoo in denial reasoning?

 

[adjusterjack]

You'll have to find out from DMHC what it's rulings are on changing the denial like that.