Why You Need to Know Your Policy

Posted By Kantorlaw || 25-Jul-2012

Save Those Envelopes!

Our client is covered by an employer sponsored group plan based in New York. The Plan denied our client's residential treatment for her anorexia based upon medical necessity. We submitted a timely appeal. On April 23, 2012, we received the Plan's response denying the appeal based upon medical necessity. The appeal denial is dated April 11, 2012. Since it seemed odd we did not receive the Plan's April 11th letter until April 23rd, we decided to investigate further and review the Plan. This Plan includes an interesting provision,

"[The Plan] will make a decision re a Standard Level 1 appeal within 15 days….if [the Plan] fails to notify you within the above timeframe…we will reverse any adverse determination that was based upon medical necessity and /or because the service was deemed experimental…"

We immediately checked the postmark on the Plan's envelope which enclosed the appeal denial and discovered it was postmarked April 19, 2012. Curiously, April 11, 2012 was the 15th day. We contacted our client and, as expected, her copy of the denial letter and postmark included the same dates as ours. As a result, we will proceed to litigation and use these letters and envelopes as evidence to support a reversal of the Plan's adverse determination that was based on medical necessity.

The moral of this story is always refer to your Plan for deadlines and procedures and save those envelopes!

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