I feel really screwed by this claim denial of $950 for IUD device and services. The health plan is self-funded by employer and subject only to ERISA law. I have exhausted the voluntary so-called appeals process, which they made a shambles of and handled in extremely bad faith. My next recourse would be to take it to court, but I couln't pay the attorney fees to collect only $950 dollars.

This situation looks black and white to me. The coverage brochure says "Family planning supplies and services" are covered with the exceptions of "surrogate planning" and "reversal of voluntary sterilization." It also enumerates about 6 kinds of abortion that are covered.

The SPD itself does not mention family planning or abortion one way or another. Nothing is said in the exclusions to major medical benefits in this regard.

However, under the terms of the retail pharmacy prescription drug benefit, there is an exception that says this benefit excludes "contraceptive devices and therapeutic devices." To me, all that means is I can't go to my retail pharmacy, give them my prescription card, pay my $25 copay, and purchase a contraceptive or therapeutic device.

The plan administrator hasn't been willing to address this distinction and won't address the fact that none of the medications dispensed and given by a doctor are covered under the pharmacy plan yet they are still payable under major medical. They also have not even acknowledged that I am contesting the denial of physician services, which fall under physician office visits, and won't respond to this issue at all in my appeals or other correspondence.

They have violated almost every law on the ERISA books about the right to a complete and fair appeal process.

Even though this contract appears black and white to me, and I have looked over other plan benefits documents that have a separate section for major medical and for retail pharmacy plans, I really would like to find someone more expert in the field who could make a statement regarding customs in the insurance industry or who could look at these documents contracturally to see if they even have a leg to stand on to deny this claim.

I really need to get expert help from someone with experience with insurance contracts, yet on a limited enough basis that I can afford it, say 75 to 100 dollars.

Could anyone give me a suggestion on how to find someone who could help me on this, just to look over the brochure and SPD and see if they have any legitimate basis to deny this claim?

I am very frustrated by this and would greatly appreciate any advice anyone could give.

Thanks!

Have you gone to your employer (human resource dept) with your concerns? Self funded means your employer is funding (paying) the claims. In my experience when you go directly to your employer (the plan administrator's client) they may be able to help as it is their money. From what you are saying, you have a valid argument (without reading the plan in question). If you haven't gone to your employer with your complaint I would suggest you do so.

Mander, thanks for your post. If anything, I think you have reinforced to me that I can trust my own research and common sense on this and don't really need a lawyer or insurance expert to interpret this contract.

Unfortunately, as this is a self-funded plan, the fiduciaries of the plan are in the human resources department of my husband's employer, and I have communicated extensively with them and filed my final administrative appeal through them, and they are insisting this is not covered. The only justification they can give me is what is stated in this retail pharmacy plan rider and the fact they want to benefit their stockholders. They have ignored the substance of my appeal and refuse to answer most of my questions.

I am sure most self-funded health plans are handled by the employers in good faith, but I do wish to warn anyone whose plan is funded by the employer to read the fine print of your SPD carefully and ask questions before getting service. The state laws that regulate insurance do not apply to them, and your only recourse with them is with the federal ERISA laws, and even under ERISA, they aren't considered an "insurance company" so some ERISA protections don't apply to them.

If they want to deny a claim arbitrarily and in bad faith, the maximum they can lose in court is the amount of the claim they would have owed anyway, and most people don't have the resources to file a complaint in district or federal court to contest a moderate claim refusal.

I do plan to talk to the department of labor EBSA office and see what they can do. They may at least be able to apply corrective enforcement of the ERISA laws this company has violated.