Self Funded Corporate Insurance Plans?

Question

My wife requires a procedure which is not covered by my corporation’s self funded health insurance plan. Is there a form I can file with the plans TPA or with my company itself for special cases to appeal for coverage?

Answer 1

Some employers will request you use a specific form; but most do not. Most insurance companies don't require a specific form...

A well written letter, with medical records attached will be sufficient. Make sure to include a cover sheet of some sort, identifying your letter as an Appeal.
Depending on the surgery and the reason for the exclusion, you may want to include consumer based rationale as to why the service should be covered. If they don't cover it because its experimental, try to include as much research info about the procedure.... Or if they're trying to say its cosmetic, try including as much information concerning medical necessity, like medical records and test results...

I've worked in insurance and healthcare for a long time; and your circumstance is not uncommon.. I would strongly advice pursuing the appeal. Hopefully, you will have an option to use an ERO or IRO as a 3rd level appeal option. It will allow a third party, not associated with your group or insurance co to review your case.
good luck

Answer 2

Ralph,

I'm sure there is a form for an appeal of your case. If not, make one. Write a Letter of Appeal and state your case. In the letter, give the TPA, and your employer, clear, precise, information that you believe indicates that an exception should be made in this insistance. Include information that describes the problem as one that is common, and for which most other health plans provide coverage. Ask your personal insurance broker for assistance in drafting the letter. If the cost of the procedure is high, you might wish to consult an attorney to draft a letter for you.

When you send the letter, you might ask your employer if stop loss insurance has been placed on your employers self-funded plan. Most stop loss coverage, which protects the employer, has individual stop loss provisions, and agregate stop loss provisions. This protects the employer from a specific loss on any one claim and on all claims in any one year. If your employer has stop loss protection, you may also wish to send a copy of your appeal to the insurance company covering excess over the stop loss.

Last, most States have an Insurance Department or Division in State Government. Most are very consumer friendly. You might check with them to see if Self Funded or Partially Self Funded plans come under their jurisdictions. If they do, ask them for assistance.

Good Luck,

Grampy

Answer 3

"Grampy's" answer is 99% correct and I suggest you follow his advice. The only incorrect information is the suggestion that you contact your state's insurance department; also, it's my understanding that "stop loss" kicks in when COVERED expenses are paid by the Plan. If the insurer denied this service because of a plan exclusion, stop loss won't be applicable.

ALL states are exempt under ERISA from regulating self-funded plans of insurance.

If your employer's Plan Administrator refuses to reconsider, call the United States Department of Labor (www.dol.gov) and speak with someone in the ERISA division. While the USDOL doesn't investigate complaints, it can advise you whether or not the Plan's decision complies with ERISA.

If you still disagree with the Plan after doing all this, your next step is to file a lawsuit in Federal court.