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TexLaw, Attorney
Category: Legal
Satisfied Customers: 4430
Experience:  Lead trial/International commercial attorney licensed 11 yrs
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I have a question about employer provided health care. We have

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I have a question about employer provided health care. We have a high deductible health care plan and prescription drug program through my employer. But the prescription provider is refusing to cover the expenses for a chronic pain medication this year, even though they covered it last year. The prescription provider claims that the medication had a lifetime cap. But they provide no documentation to back up this claim. In fact neither the employer, the health insurer or the company can provide any documentation for the prescription drug plan, it's not covered anywhere in the summary plan description.
So I have two questions:
Is it legal to sell health insurance coverage without comprehensive documentation?
How can I force a resolution of this issue when none of the parties will talk with us?

Thank you for your question.

This certainly is an odd situation. The actual insurance policy or one of the schedules will definitely show the type of coverage that is offered for this kind of medication. The insurance company has a duty to provide you with the full documentation of your insurance policy upon request.

The first thing you should do is send off a certified letter to the health insurance company demanding that they immediately provide you with the requested documentation.

At the same time, you should file a complaint with the New York State Department of Financial Services at:

This is the state agency which regulates insurance in NYS.

These two actions should get the ball rolling.

You need to also check in the documentation that you do have how to contest a denial of coverage. There should be an appeal procedure that your health insurer provides which you should initiate to contest their determination that there is a cap on the coverage.

Please let me know if you have any further questions. Please also kindly consider rating my answer positively so that I am compensated by the website for my work on your question. Rating positively does not cause an additional charge and does not prevent us from further discussing your questions.

Best Regards,
TexLaw and 6 other Legal Specialists are ready to help you
Customer: replied 4 years ago.

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!

Customer: replied 4 years ago.

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 for getting back to me.

I hate it when these insurance companies do this sort of thing. A month to wait for your prescription drug is ridiculous.

I think you should go ahead and file with NYS. I also think you should tell your plan administrator that you are filing. The goal is to get them to hurry the process up. The denial is wrong since it's not an excluded drug and has been prescribed to you.

The complaints with the state have limited effect. They do not usually result in an order from the state until a investigation period has gone by. However, the mere fact that a complaint has been filed can spur the insurer into action.

In regard to bringing a class action suit, this is not done in a complaint to the State. Rather, you would want to simply file an action against the company directly in your own name for breach of the policy and wrongful denial of benefits.
Customer: replied 4 years ago.

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?

"bad faith" is the big one.

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