Health Insurance Help

Reader’s Question:

I have an employer-based health insurance. What’s my protection before federal ERISA law?

Jim

Billings, MT

 

It’s good that you asked, Jim.

Our federal law always has protection for employees with job-based health insurance. You can have additional protection from the federal ERISA law like an impartial process for reviewing appeals, specific deadlines in returning decisions on claims and appeals, required speed in processing your claim if the doctor declares its urgency, and 180 days at least for you to file an appeal.

In case your appeal of a claim decision is not successful, you can resort to consulting your state’s insurance authority as your last shot at getting the treatment or service covered. External panel of experts may review your claim as the state allows this and the panel’s decision becomes the final word in your case.
You must learn all your protections from your state. There are some states which allow patients to sue their health insurers for malpractice is a claim or treatment is denied. Your state should have laws for handling such disputes.

There can be an exception such as when you are enrolled in a self-funded plan if your company pays employee’s medical bills and takes on the risks of insurance. It is in this case when the law is the only potential recourse for disputing claims beyond the internal appeals process, which cannot be a very good option. At this point, you might want to contact you human resources department to help you resolve your issue.

The best advice I can give is for you to know the structure of you plan so you can resolve issues fast and in the most economical way.