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Eligibility Denial

Guest Mfcavo

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A retired participant in medical plan dies and her husband is told he is no longer be covered under the retiree plan. An inquiry tot he plan administrator results ina letter that say "There is no evidence that you should be covered" but includeds a bullet point dewscriptionof plan that says that spouses of retirees are covered if the retiree has any remaining credits which weere earned at rate of 1000 credits o for each year of full time employment. When PLan Administrator is asked for proof that credits have been exhausted, the reply (by telephone) is that "If you want more infomration, w you will have to provide a supoena"

My question is, assumiing I want to sue, what type of action is it.? No actual claims have been denied yet.

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If the employer is not a government or a church, it has a prescribed procedure for addressing claims, and a claim about eligibility should be subject to the procedure. The procedure must be formally invoked, which may take a written claim, delivered to the fiduciary of the plan that has responsibility for claims adjudication. If the claim is denied, an explanation is required and the claimant is entititled to see anything that was considered in making the decison. It sounds like information about credits would be included in the information considered in denying the claim. You need to follow the formalities of the claims procedure, including appeal of a denial. The plan is required to explain the claims procedures. Ask for a copy or a summary. If you do not follow the procedures, including time limits, you will not be able to sue if your claim is ultimately denied under the procedures.

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  • 11 months later...

I would suggest that you try your best to get a copy of your wife's medical plan's Summary Plan Description (if the medical plan is not a federal government plan).

Then read it and educate yourself on the terms & rules of the medical plan regarding a situation like yours. Only after you make yourself knowledgeable about the plan's rules, can you then decide how to proceed.

You should also call the US Department of Labor (Employee Benefits) and explain your situation.

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