Insurance benefits provided by your employer benefit plan are usually governed by the federal laws of ERISA (Employee Retirement Income Security Act). Not all plans are insured, and instead may be self-funded. But, when they are insured, your dealings will almost always be exclusively with an insurance company.
Under ERISA, you are entitled to receive, upon request and free of charge, "reasonable access to, and copies of all documents, records, and other information relevant to your claim for benefits, including any guidelines relied upon in making this determination.”
The quote above is standard boilerplate language that appears at the end of almost every denial letter issued by a health, life, or disability insurance company when the benefits are governed by ERISA. In such a case, an insurer is required by federal law to give you access to almost all of the documents they utilized in making a claim determination. This includes, but is not limited to, the policy or plan, the medical records, internal notes and memos, and the notes of their reviewing physicians.
The verbiage will vary from carrier to carrier, sometimes being extremely detailed. For example, one carrier we dealt with recently put this in their denial letter:
“You have the right to receive, on request and free of charge, a copy of any internal rule, guideline or protocol, as well as any other documents relevant to your appeal that we relied on in making this decision. You also have the right to receive, on request and free of charge, an explanation of the scientific or clinical judgment that we relied on in making this benefit decision, as well as the diagnosis or treatment codes, and their corresponding meanings.”
Seems pretty simple right? Just send them a written request and you get all the information you could ever want to know about why your claim was denied. After all, ERISA also says they can be fined $110/day if they fail to timely honor your request. Well, like most things in life (or rather, most things in life where an insurance company is involved), a seemingly simple process can be downright maddening!
Take the following story into account when you experience frustration dealing with simple, federally required requests of your own…and remind yourself that if a lawyer is facing this much trouble, then it’s not your fault when you face the same resistance.
• A new client retains Kantor & Kantor, LLP after his 91-year-old grandmother has her skilled nursing claim denied by her health insurer;
• Kantor & Kantor, LLP immediately sends a request to the insurer for the claim file;
• A week later, we get a letter from the insurer saying they have received our request for an appeal and that we can expect their decision soon;
• That same day, the insurer sends another letter saying that the appeal isn’t going to be processed because no medical records were provided;
• Kantor & Kantor, LLP also sends a letter asking for an extension of time to appeal the denial;
• The insurer again responds that they have received our appeal request and will render a decision soon;
• Kantor & Kantor, LLP sends another letter, making it abundantly clear that the previous 2 letters were requests for the claim file and an extension, and not the appeal itself;
• The insurer sends 2 more letters, both of which say that the letters we sent do not qualify as appeals (THANKS FOR TELLING US WHAT WE JUST TOLD YOU!), but doesn’t produce any documents from the claim file;
• Kantor & Kantor, LLP submits an 800+ page appeal packet on behalf of the client, making sure to point out their errors in our multiple requests for the claim file;
• The insurer denies the appeal in basically 1 sentence, even though their position is completely contradicted by the 600+ pages of medical records;
• Kantor & Kantor, LLP sends another request for the claim file, this time quoting word-for-word for the language that appeared in the denial letter that was just issued so there can’t possibly be any confusion on their end (see above);
• (Can you guess what happened next?)
• The insurer sent yet another letter saying they have received our request for an appeal and that we can expect their decision soon;
• I decided to call instead of sending another letter, spoke to a pleasant woman in their claims department, explained the comedy of errors to her, and got her to fax me a letter confirming our conversation and assuring that the requested documents will be sent ASAP;
• 10 days later, I got a packet of documents, 90% of which have nothing to do with the claim at issue;
• I called again and spoke to a supervisor who said she understood the problem and would call me back later that day with how she was going to get me the requested documents…she never called me back.
We offer you this story not to discourage you, but rather to offer you some encouragement for when you feel like you’re ramming your head into a wall while dealing with your insurance company. It’s not you…it’s them. They purposely make the process difficult because they know the vast majority of people will just go away in the end.
So, the best thing you can do when facing resistance from your insurer is to keep fighting! Please remember that if that fight becomes too much to deal with on your own, you can contact our office for a no cost consultation. We might be able to help level the playing field.
We understand, and we can help.
Kantor & Kantor, LLP (800) 446-7529