Looking for help

[Guest sylvia]

I am hoping someone out there can help me and my co-workers. We are covered under a "self-funded health" plan and are having a lot of problems. The first of which is claims that just don't get paid, sometimes for three months or more.I know lots of people in collections from this.

When we call the insurance company, they say call the employer, and vise-versa. We are also all being told on the phone that our plan is not subject to any time limits for our claims to get paid, something about they are exempt from all of that.

I also know lots of people in our plan geting their claims denied for a "pre-existing condition". There doesn't seem to be any rules for this in our plan except if its a big bill its pre-existing and they wont pay. We cant get any help calling the insurance company or our own employer. Can anyone tell me who or what agecny to call for help or to lodge a complaint?

[Guest jamesfdavis]

Try the U.S. Department of Labor's Pension & Welfare Benefits Administration (PWBA). It might have a local office in your area -- look under the U.S. Government listings in your phone book. However, if you're employed by a local or state government, the PWBA probably does not have jurisdiction (an ERISA exemption).

Also try contacting your state Department (or Commission) of Insurance. This could be a stretch because your plan is self-funded, but the state may have oversight authority over the insurance company as a claims payor.

[jeanine]

The first thing you must do is get a copy of all relevant documents for your plan. At the absolute minimum you should have a benefits booklet. That booklet must contain language pertaining to HIPAA, a federal law that sets limits on pre-existing conditions. Ask your insurance company for a HIPAA notice if you can't find any information about it in your plan booklet. As far as your claims not being paid timely there could be other explanations. The insurance company you describe is likely the third-party administrator of your company's plan. If the company does not fund the plan, i.e. forward the proper amount of money to cover the claims, the TPA won't pay the claims.

[Guest Brook]

In reference to jeanine's suggestion that the plan sponsor might not be funding the claims, does anyone know the liabilities of such inaction? Are self-funded plans subject to any requirements for timely payment? Does ERISA fiduciary responsibility cover timely funding of claims registers?

[jeanine]

Unfortunately, when a company is not funding the plan to pay claims, this usually signals severe financial problems with the company. I'm not saying this is what is happening in this particular situation. However, if the company files bankruptcy, there is very little relief for the plan participants. If the plan is set up to pay claims through a trust, the trust is usually more secure than a company funding from its assets from month to month. Yes, there are fiduciary duties involved in funding, and the new claims procedures (effective 2002) attempt to address the issue. But if there is no money, there's no money.

[KIP KRAUS]

Sylvia;

Time to get back to everyone so we know how things stand. At this point everything is based on assumptions. What progress or actions have you taken?