claim approved by fsa management & employer refuses to issue the r

[Guest jane caplan]

my claim for 150.00 has been approved by the FLEX One account manager for my 1999 account.

the employee has been contacted twice by FLEX One and the employer refuses to issue my check.

What is my next step in order to get my account reimbursement from the employer?

[Lisa Hand]

Please give us a bit more information.

What is your plan's deadline for claims submission for the old plan year?

Have you received a denial letter? If the claim is not going to be paid, a written explaination must be forwarded.

What reason, if any, has been given for the check not being issued?

[KIP KRAUS]

Read the plan description to determine who has ultamate authority to approve plan reimbursement.

What is the employer's reason for not paying the claim?

Was the claim timely filed?

April seems to be a long time for 1999 incurred claims to payed on a run out provision.

[Guest jane caplan]

quote:

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Originally posted by Lisa Hand:

Please give us a bit more information.

What is your plan's deadline for claims submission for the old plan year?

Have you received a denial letter? If the claim is not going to be paid, a written explaination must be forwarded.

What reason, if any, has been given for the check not being issued?

The claim deadline is April 30. My claim was filed on February 20 and approved for payment 3/1/00. I called on March 21st to FlexOne to ask the status of my claim. I was told approved and that the employer had called them back to question if the 1999 money would still be mine. The FlexOne employee stated they had explained to the employer that yes the claim was valid the account was mine and that the employer should issue the check.

April 10th I had not recieved a check so I called FlexOne again to check the status of my approved claim. Still not payment from the employer.

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[KIP KRAUS]

Try contacting the employer direct.

[Guest EMK]

Were your expenses incurred while you were still employed by the employer? If not, they may not be eligible expenses.

[pjkoehler]

As a legal matter you need to determine who the fiduciary is that is responsible for adjudicating your claim. This will be spelled out in the plan document and the summary plan description. Make sure you have current copies of both. If you don't, submit a written request to the plan administrator for these documents. If you don't know who the plan administrator is, ask the HR department. A Health FSA is an ERISA welfare benefit plan. ERISA provides that plan participants are entitled to receive these documents within 30 days of your written request (subject to payment of reasonable costs of duplication). Violations may result in a $100 per day penalty in the discretion of the court. The plan is required to maintain a claims procedure that satisfies ERISA's maximum processing times for initial decision on the claim, administrative review and appeal of a claims denial. Make sure you understand the procedure, have obtained the prescribed forms for filing claims and keep track of the review periods. At a minimum, ERISA requires the plan's claim's procedure to provide a claimant whose claim is denied with a written explanation of the terms of the plan that governed its decision and an explanation of the plan's claims procedure and any right you may have to submit new facts or arguments to support your claim. Ultimately, after you have exhausted your administrative remedies under the plan, you may choose to bring a civil action against the plan fiduciaries who were responsible for the denial on a theory of the wrongful denial of your benefit. While many third party administrators will conduct the initial review of benefit claims, it is rare to say the least to find one that accepts fiduciary responsibility. It is more likely that a benefits committee, HR staff or some other arm of the employer, has this formal responsibilty. There is nothing improper about the fiduciary's exercise of its authority to disregard the determination of a nonfiduciary. In fact, it would probably fall below the standard of fiduciary responsibility for the plan fiduciary not to override the TPA's determination. While you want to be sure that you are accorded full access to the claims procedure, the ultimate call on the merits of your claim is probably not with the TPA.

[This message has been edited by PJK (edited 04-12-2000).]

[This message has been edited by PJK (edited 04-12-2000).]

[Guest]

PJK, could it be this isn't an ERISA plan because it's just FSA? In any case, if the employer doesn't pay, you need to keep bothering them until they do. You could try calling the Dept of Labor in your area.

[pjkoehler]

quote:

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Originally posted by dsilver:

PJK, could it be this isn't an ERISA plan because it's just FSA? In any case, if the employer doesn't pay, you need to keep bothering them until they do. You could try calling the Dept of Labor in your area.

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ERISA defines a "welfare benefit plan" as any plan, fund or arrangement established or maintained by an employer, through the purchase of insurance or otherwise, for the purpose of providing certain kinds of benefits including medical, surgical or hospital care benefits or benefits in the event of sickness or accident. 29 USCA Sec. 1002(1). Proposed Treasury regs define the term "flexible spending arrangement" to mean a benefit program that provides employees with coverage under which certain types of expenses may be reimbursed, including, in the case of the Health FSA, expenses that are excludible under Code Section 105(a) under an "accident or health plan." Prop. Reg. 1.125-2, Q&A-7. Also, the Health FSA may not elminate substantially all risk of loss to the employer maintaining the plan. Id. It may well be that a Health FSA qualifies for the "small welfare benefit plan" exemption from the reporting requirements under ERISA, but, it would be quite a stretch to argue that such a benefit program maintained by a nongovernment, nonchurch private sector employer, is is not an ERISA "welfare benefit plan," covered by Parts 1 (information and reporting), 4 (fiduciary responsibility) and 5 (reporting and enforcement) of the Act.

[This message has been edited by PJK (edited 04-13-2000).]

[This message has been edited by PJK (edited 04-17-2000).]