1. Obtain a full copy of your Plan. The full Plan will not be a benefit summary or a print-out from a website. It will be, on average, at least 50 pages long. The claims administrator will likely not have a copy of the full plan. You can request a copy of the full Plan from your Human Resources department.
2. Read the Plan. A customer service representative for a health insurance company or claims administrator may tell you what your benefits are over the telephone. You cannot rely on what a representative tells you over the phone. The Plan document controls the benefits available, not what someone tells you over the telephone. Ask the representative to tell you what specific Plan provision they are referencing and ask them to send you a letter documenting what they are telling you.
3. Look outside the Plan. Although the Plan should include all terms of coverage, often the claims administrator will apply their own criteria or guidelines to claims decisions. You can find many criteria or guidelines for claims administrators such as UBH, Cigna, and Aetna on the internet.
4. Is the Plan insured or self-funded? Insurance law applies to insured plans, not plans that are funded by the employer. So, for example, mental health parity laws do not apply to self-funded plans. Large employers such as AOL and Wells Fargo, fund their own plans.
5. Time to appeal a claims decision. Read the appeals or grievance section to determine your appeal rights and deadlines. The first appeal must be submitted within 180 days pursuant to ERISA. However, a second level appeal can be a much shorter time period, as little as 30 or 60 days!
6. Read the definitions. Definitions for certain levels of care, such as skilled nursing or inpatient hospitalization, will inform you as to how the Plan will classify your treatment.
7. Statute of limitations. This will be the period of time by which you must file a lawsuit to obtain disputed benefits. To file a lawsuit for benefits pursuant to an ERISA plan, you must first submit appeals (at least one, but no more than two). The statute of limitations may appear in a section titled “Legal Action.”
8. Who is the Plan Administrator? Look for a name and address of the Plan Administrator in the Plan. If your claim has been denied, send a written request to the Plan Administrator for all plan documents. The Plan Administrator is required to provide the plan documents to you within 30 days. 29 U.S.C. § 1024. Federal regulations allow you to file a lawsuit to seek penalties from the Plan Administrator in the amount of $110 per day for each day the plan documents are not provided. 20 U.S.C. section 1132(c)(3); 29 C. F. R. § 2575.502c–1.
9. Calculate your deductibles, co-pays, co-insurance. Yearly deductibles, co-pays, and co-insurance are confusing and can be applied incorrectly. Brush up on your math to do the calculations yourself to ensure that your claims are paid in full.
10. Find out who has “discretion” to decide your claim. Discretion is a key word in the world of ERISA. It means that the entity with “discretion” has permission to decide everything about your claim. An example of discretion in a Plan may be: “Anthem Blue Cross has discretionary authority to determine benefit eligibility and construe the terms of the Plan.” If the entity who has “discretion” is also the entity that pays the claim, then the entity has a conflict of interest.