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Who is fiduciary ? (re: fully-insured group medical)

Moe Howard

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1. The following are the players in a fully-insured group medical plan.

Association (the policyholder)

Member of the association (an employer)

Participants (employees of Member)

Insurance company

TPA (claims administrator ...hired by insurance company)


QUESTION: Which of the above is a fiduciary of the plan?

2. Another Question:

Participant received medical services. TPA processed the claim. TPA tells participant that TPA mailed an EOB to participant timely, but participant cliams that he never received the EOB in mail. Participant calls TPA and requests TPA to e-mail a copy of that EOB to participant. TPA says it can't e-mail a copy... but will mail it again. Participant never gets it in mail. Participant calls TPA again and TPA accuses participant of being rude and hangs up on him.

How in the world is participant suppose to get the EOB? Does DOL even require that he must be given an EOB? Who has jurisdiction over requiring that an EOB be furnished to participant .... (DOL, State Insurance Dept, ???)

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1. Except for Participants, any and all of the others could and might be fiduciaries. It depends on their duties, responsibilities, control, authority and actions.

2. Not knowing both sides of the story, I can only suggest that the Participant verify the address used by the TPA and then request that the EOB be sent by Certified mail or with other proof of delivery.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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