Wow, Thanks, XXXXX XXXXX excellent advice. I completely forgot about checking for denial of claims clause in the SPD. Thank you again. I expect that things will bog down if I have to actually file a claim, but let's see where this goes!
Hello ZDNLaw, I have follow up questions. After further review, I found the section in my summary plan description (SPD) that describes the prescription drug plan and the claims and appeals process. Both sections are quite detailed. I've reviewed the prescription plan and the prescription we are being denied is not on the list of excluded drugs. The provider claims that they are 'reviewing' our claim. This 'review' has been going on for a month and is an apparent attempt to avoid the claim denial and appeals process, since a claim denial requires a written explanation and the appeals process can be brought before a 3rd party arbritator.
So my questions are;
Should I file a complaint with NYS?
If I do, should I inform the Plan administrator that I am entering a complaint against them?
How effective is a single complaint? Are there any resources available to begin a class action suit? I suspect that the provider does this often, and most people just don't know their rights.
Thanks again. I will file and send a registered letter to my plan administrator. We've been told by our pharmacy that the insurer did deny the claim (I just found this out now), but not directly and not in writing. So we are certainly going to bring this to the attention of others. Are there any keywords that can be put on the letter envelope to the administrator that will get their attention?
DISCLAIMER: Answers from Experts on JustAnswer are not substitutes for the advice of an attorney. JustAnswer is a public forum and questions and responses are not private or confidential or protected by the attorney-client privilege. The Expert above is not your attorney, and the response above is not legal advice. You should not read this response to propose specific action or address specific circumstances, but only to give you a sense of general principles of law that might affect the situation you describe. Application of these general principles to particular circumstances must be done by a lawyer who has spoken with you in confidence, learned all relevant information, and explored various options. Before acting on these general principles, you should hire a lawyer licensed to practice law in the jurisdiction to which your question pertains.
The responses above are from individual Experts, not JustAnswer. The site and services are provided “as is”. To view the verified credential of an Expert, click on the “Verified” symbol in the Expert’s profile. This site is not for emergency questions which should be directed immediately by telephone or in-person to qualified professionals. Please carefully read the Terms of Service (last updated February 8, 2012).