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Self-funded Plan (ERISA) - - Plan Documents not signed until months after effective date

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SaulGoodman

New member
What is the name of your state? State: CO

I'm covered under a self-funded Plan through my employer and I incurred a medical service in June of this year that the Third Party Administrator denied as an exclusion. We switched to a new carrier on 11/01/17.

Although the coverage was effective on 11/01/17, I was never given a copy of the Plan Document to know this service wasn't covered. When I finally got a copy of it after my service was denied, I saw our human resources person never actually signed it until April 15th of 2018. Yet, it claims it was "retroactively" effective back to 11/01/17.

How can they retroactively make a document effective back to 11/01/17 when it wasn't legally executed (by signing it) until 04/15/18? And how was I supposed to know this service wouldn't be covered when I never got a copy of the Plan Document?
 


PayrollHRGuy

Senior Member
The plan document may well have not needed to be signed prior to it being effective.

You do like many normal medical plans require. You have the procedure pre-approved.
 

Whoops2u

Active Member
Man, it's like Sandpaper Crossing all over again. You've got to get the little things right to get away with it.

I think the bottom line will be the person getting the service has the duty to know how it is going to be paid. This problem comes up time and time again without the complications you mention in regards to purchased health insurance. The person does not know what is covered or know procedure to get what is covered and ends up owing a bill they thought was going to be paid by insurance.

The unsigned plan document is going to be something that really doesn't help you that much. Are you arguing that you don't have any insurance/indemnification from the company's ERISA plan?
 

SaulGoodman

New member
How do I get the procedure pre-approved when I don't have a Plan Document that tells me what requires approval? Under our old Plan not every procedure required pre-approval, nor would the carrier do a pre-approval if it didn't require it.

How do I know what is or isn't covered by the Plan when I've never been given a Plan Document that tells me what us and isn't covered? For example (not what I had done) our old Plan covered gastric bypass. This one doesn't. But no one was ever given a copy of the new Plan Document that showed the change.

And again, how is the Plan then effective before it's even signed and executed?
 

Whoops2u

Active Member
How do I get the procedure pre-approved when I don't have a Plan Document that tells me what requires approval? Under our old Plan not every procedure required pre-approval, nor would the carrier do a pre-approval if it didn't require it.

How do I know what is or isn't covered by the Plan when I've never been given a Plan Document that tells me what us and isn't covered? For example (not what I had done) our old Plan covered gastric bypass. This one doesn't. But no one was ever given a copy of the new Plan Document that showed the change.

And again, how is the Plan then effective before it's even signed and executed?
Again, your argument is that no plan covers you?
 

PayrollHRGuy

Senior Member
You get it pre-approved by contacting the plan administrator.

As I said the signature may not mean anything.
 

SaulGoodman

New member
I'm not saying I wasn't necessarily covered under a Plan; I'm saying I was covered under a Plan that never told me what the Exclusions are...so then legally how can those Exclusions apply?

Per www.shrm.org:

"ERISA requires plan administrators to disclose to plan participants any changes that reduce covered services or benefits within 60 days of the adoption of the change through a revised SPD or a summary of material modification."

Never happened until I requested a copy of it after services were denied.
 

cbg

I'm a Northern Girl
And how do you know this was a change that reduced benefits? Do you know for a fact that it was a covered benefit previously?
 

Whoops2u

Active Member
I'm not saying I wasn't necessarily covered under a Plan; I'm saying I was covered under a Plan that never told me what the Exclusions are...so then legally how can those Exclusions apply?
Because that's the Plan?

Either you were covered under the plan or you were not. If you were covered by the plan you have all the duties and benefits under the plan. Exclusions are a part of the plan.

If you were not notified (nothing to do with some signed agreement) 60 days before the change AND it was a "material reduction" AND it was made during the plan year (not between) AND the company intentionally did not inform you, THEN I believe the statute gives the government the ability to fine the business $1,000 per person not notified. I don't see a private remedy.

I'm wrong. There IS a private remedy.
http://apps.americanbar.org/labor/lel-aba-annual/papers/2000/wahle.pdf
 
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Taxing Matters

Overtaxed Member
Never happened until I requested a copy of it after services were denied.
Did you ask for a copy of the plan or ask what exclusions there were before the procedure? Never simply assume that something is covered. Always ensure you have a copy of the latest plan and read it to know what is covered.
 

cbg

I'm a Northern Girl
Nor have I seen any evidence so far that the procedure in question was clearly covered prior to the change in plan here. And if it wasn't, no notification is required by ERISA anyway.

It amazes me how many people know that there's been a change to their plan and never bother to pick up the phone and ASK A QUESTION instead of making assumptions about what is and is not covered.
 

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