If you participate under an employee health insurance plan, how exactly does your plan operate?

I am really steamed. I just found out that my health insurance will not pay for bunion surgery. My big toe is so affected that it is causing problems for my second toe. I didn't know this. I thought I was losing fat padding underneath my second toe, at least thats what it feels like when I walk. But my doctor told me that because my problem is getting worse it is causing my other toe to do more work than it's suppose to.

In my organization we have a lot of unhappy campers with our insurance policy. We have only one administrator who tells us what we can and can't do. There isn't a board to appeal to and I never hear of our insurance being reviewed every so often. What should the credentials be of a insurance administrator? What exactly are our rights? Is it normal that only one person in the organization interprets what the policy is? We have over 1500 employees.

Tomorrow, I am going to our insurance office to find out where it says we don't pay for bunion surgery. I don't know how else to put this, but our administrator has held such an iron clad fist over our insurance no one dares confront her. Not even her supervisor! I know that this will make her very defensive and abusive. I've been lucky and I've never had to deal with her at all on other issues like other people have. I never thought that something that could be so painful would be turned down by my insurance.

Is your plan self-funded? Sounds like it may be. At any rate, there should be a booklet and a copy of the plan itself available to you. If it is not self-funded, in other words someone like Blue Cross or Humana or whatever, then you can call them directly and ask. You should have an insurance card with their contact info on it.

Definitely get something from the administrator on what the insurance plans covers.

I use to work for a company that self-funded but still used an insurance company to handle the claims administration, so everything still had to be in writing somewhere what was covered, proecedures, etc.

Once you've seen your administrator, please report back what you have found out.

Yes, even if your company is self insured there is an insurance company that handles that plan. The company I worked for was self insured but we still had papers to be filed, a policy to refer too, etc. Ours was through DCT in Ohio. You need to find out who it is that manages your plan (company not person) and deal directly with them.

However, when your company is self-insured they are usually very strict about what they allow done. We all came home from work one day on a Friday evening, with letters in our mail, telling us that our boss had cancelled our entire group policy, for health ins. It was effective exactly 3 days later. We didn't even have time for one last Dr. visit or to even get prescriptions called in. Talk aboput a bunch of angry people. Bottom line, we had no recourse except to quit our jobs if we wanted. We spoke to attorneys, state ins. regulation board. Nothing was available for us to do. Also, because he cancelled the entire group plan, none of us were eligible for COBRA. Things in medicine and ins. are changing. I have no idea what the solution is.

Cherry52, thats awful. Yes, we're self-funded but in our particular case our administrator can't pull the plug on us because we are shareholders so to speak.

According to her quote from my doctor's office "bunions, calluses and corns are not covered by insurance". Well, calluses and corns are not the same as bunions which involve bone, not tissue.

But in self-funded organizations isn't there a denial letter, a grievance procedure for the employee? We have neither. I just so far have her veral denial through my doctor's office. And in your organization, what are the qualifications of the Insurance Manager or Insurance Coordinator? I have the feeling that in our organization our Insurance Coordinator is interpreting the policy all by herself. In fact, I know she is. No one dares confront her and when they do it's a very shocking experience. You just can't imagine.

Do you mean to say there's no grievence procedure in your plan? If that is the case, have you checked with your states department of insurance?

If it's a self-funded plan there are no state grievance options available. You can follow federal ERISA, but that's usually not as good as some state's grievance options (though some states don't have grievance options). Insurance companies treat self-funded plans like any regular one except that the group can request what they do and don't want covered, etc. And unfortunately, the plan administrator may be some bureaucrat who cares more about saving the company money than offering the best coverage for their employees. But at the end of the day, it's your company's money so that's their choice. Like others have said, the insurance company just basically "runs" it for them so you'll have to take it up with your company if that's the case. Good luck.