YOUR NEEDED MEDICAL TREATMENT IS DENIED COVERAGE, WHAT HAPPENS NOW?

Your father, your mother, your spouse, your son, your daughter, someone you know has been diagnosed with a non-surgical cancer. The only treatment available is chemotherapy with stem cell replacement. The new treatment is available, and though not yet widely practiced, the treatment is not experimental. Clinical trial tests show positive results with the proposed treatment and your doctor and hospital recommend you proceed as soon as possible.

Your insurance is carried through a plan provider at your company. You submit the claim for the planned medical treatment only to see your employer’s plan
insurance carrier refuse to pay for the treatment, claiming it is experimental.
Your doctor and hospital cannot begin treatment unless insurance payment is
guaranteed or unless you come up with the money, at least, $100,000 to pay for the treatment.

What do you do?

More than likely you are going to have to file an ERISA claim.

ERISA is the Employee Retirement Income Security Act created by Congress in
1974. It is a federal law that sets the minimum compliance standards for health
and pension plans in private industry to protect you, the individual, from
arbitrary acts of the insurance companies. To fall under ERISA, the plan for
health or insurance or pension coverage, must be established or maintained by
the employer for the purpose of providing medical, surgical, hospital care,
sickness, accident, disability and other benefits to individual participants.
ERISA does not apply to federal or state government plans, churches, self
employed person, partnerships, or plans that cover workers compensation or
unemployment. ERISA also pre-empts almost all state laws, thus any ERISA action
is going to occur in federal court.

So what do you do in this situation?

This first thing to do is obtain a complete copy of the plan that covers you.
The plan should be contained in a booklet or other document form. The plan book
will provide specific processes and steps that you and the insurer must follow
when a claim for coverage is being denied. The plan will outline the manner in
which an insurer must provide detail as to why your claim for coverage was
denied. It will also explain how you must proceed when coverage is denied and
the administrative process you must follow. The plan will also provide
timelines you must follow. Everything in the plan must be followed in detail
and responded to in a timely fashion. Your responses are key to success and
must be recorded in writing. You should obtain and submit letters from your
doctors and hospitals supporting the use of the recommended treatment. All this
information will be contained in the administrative record. The administrative
record is vitally important as it will be the only record of the case should you
have to appeal the continued denial of your claim to a federal court. Once you
have exhausted your administrative processes with the insurer, then you have
only 60 days in which to file your appeal in federal court. There is no right to
a jury trial and your recovery is limited to the plan benefits and perhaps
attorneys’ fees. There are no punitive damages allowed.

Filing and proceeding with an ERISA claim can be a confusing process. If you
are faced with a denial of medical coverage as being “experimental” or “not
medically necessary” or long term disability coverage that fall under ERISA
regulations, then you must act promptly and in a specific manner in order to
obtain your needed coverage.