BetterCallSaul

Actually the conclusion I've come to is I'm being told it's "SOP" but no one can explain to me how it doesn't violate the letter of the law of ERISA. Which to me is akin to saying it's only illegal if you get caught because as someone else said well, the risk of a lawsuit or audit is low. That doesn't make it legal and when you do what I do, you assume every file has a chance of ending up in court. And now one has explicitly accusing the plan of these very violations. If I'm that fat off base, apparently an ERISA attorney is as well. So I'm going to talk to an attorney and then the DOL if need be. But needless to say, I agree on the new job. Thanks for all your input. I do appreciate it.

I don't want to get into too many specifics for obvious reasons, but I'll share that I work for a Third Party Administrator. Hence how I know dozens of plans are potentially affected. I'm also the one responsible for denying the aforementioned person's claims because of an exclusion that may not have been legally valid, which I was unaware of until the lawsuit was filed. So I may be responsible for unintentionally ruining a man's life (and that of his family)financially when he's also trying to recover physically from something horrific. If it was all done above board with the i's dotted and t's crosses I'm more pragmatic about it. It's part of the job. If the Plan doesn't cover something, it doesn't cover something. But if it wasn't and beyond that even more lives are being affected negatively not only by files I handle but others I work with because of this...that's not something I can abide by. And while I appreciate all your thoughts and insights based on your experiences, what I can find in other sources (some of which I've provided) and even reading similar lawsuits seems to contradict at least the technical letter of the law that this isn't overreacting and just a minor thing. I can also share I'm not the only employee here who shares these concerns so it's just not something rattling around solely in my head

Sorry if my tone seems angry; it's not directed at any of you and I appreciate your input and insight. There is more to the story and it just doesn't affect one plan, it potentially affects dozens. I can tell you that that I know for a fact the SPDs are being distributed late, that there are material reductions always being made (a new SPD is always generated from scratch for every plan so while some benefits/exclusions/definitions etc. may remain the same from the old one, most are changed) without participants being notified (the SBCs do not address these reductions, particularly UCR reductions and how they're calculated --Google Acosta v Macy's for more on that if you wish), and there's already been one lawsuit filed against a plan due to this issue because hundreds of thousands of dollars were denied on someone based on an exclusion he was never made aware of because an SPD was never given to him. My concern now is that the same type of lawsuit could be brought against all these plans and they're being put needlessly in a risky situation, some or most without even the knowledge or realization they're in that position. Because according to this and multiple other sources...these are exactly the type of things the DOL would look for in an audit. https://www.onedigital.com/blog/dol-health-and-welfare-plan-audits-the-sobering-truth/ So I'm just trying to gather as much information and insight into this before I decide what I'm going to do about it. Because legally and ethically I feel like I have to do something if this is truly the case.

1. Understood. 2. While it's more likely to be read, ERISA does still mandate Participants are to be provided with a copy of the Plan Document. 3. Saying it's SOP is akin to saying everyone does weed--that doesn't mean it's legal. ERISA mandates the Plan Document is to be given to a Participant either 60 or 120 days maximum after the effective date. In this example, not only did that not happen it wasn't even signed until well after that (and there is no board resolution or anything of the sort on file). So a Participant goes to the DOL with this and audits the Plan, they're just going to shrug their shoulders and say it's SOP and who cares if the law was followed? I find that hard to believe. Especially given recent articles about upticks in DOL audits.

Sorry. Let me be a little more specific. Plan was fully funded up until 12/31/17. On 01/01/18, Plan becomes self-funded. The self-funded Plan Document (the SPD and Plan Document are the same in this case) isn't drafted until weeks or sometimes months after 01/01/18--and then not finalized (approved) by the Plan and formally signed/adopted until 07/15/18 and then distributed to Plan participants sometimes afterwards with a retroactive effective date of 01/01/18. However, the Third Party Administrator has been paying and denying medical claims (I. E. denied as not medically necessary, experimental, exclusions, UCR, etc. et al) based on the draft that wasn't signed until 07/15/18 and that Participants haven't even seen a copy of until after that. The question is, how can claims be (more so denied as no one cares when things are paid) denied based on a document that didn't exist until months after the supposed effective date and when Participants have never been given a copy of it?

A health plan under ERISA is supposed to go into effect 01/01/18. The Plan Document isn't finalized or signed by the Plan until 07/15/18, yet it claims to be "retroactively" effective back to 01/01/18. In the meantime, claims have been paid and denied based on a Plan Document that was never signed or distributed to Claimants until after it was signed. Is this on the up and up or not?