Q:My doctor has recommended a course of treatment. What should I do to prevent possible later problems with my Group Health Plan?

A: Your Group Health Plan sets the limits on what it will cover. You should become familiar with your Group Health Plan early in the treatment process. If you do not have a copy of your plan, make a written request via certified mail return receipt requested to your Personnel Department at work. You need to make a written request to get a copy of both the summary plan description and the plan. Both documents are important. Follow the plan's directions, and look for any "pre-certification" requirements. (If your plan has pre-certification requirements, you will need to get the approval of the group health plan before treatment begins.) You should make written inquiries and insist on written responses.

 

Q: You say I have to get the summary plan description and a copy of the Plan. What if my company refuses to give copies to me?

A: The plan administrator may make a reasonable charge for any copies you request. The plan administrator must make every effort to provide you with the information or documents you request within 30 days after you request them. The plan will notify you if it needs more time to comply with your request. If you do not receive the materials you request within 30 days, you may sue in a federal court. The court may order the plan administrator to provide the materials and pay you up to $100/ day after the 30 days.

 

Q: Will my group health plan cover all forms of treatment?

A: You should always check your group health plan to see what it will and will not cover. Group health plans that cover treatment for cancer, for example, generally cover most recognized forms of treatment: e.g., chemotherapy, radiation therapy, surgery, and so forth. However, most group health plans have provisions that exclude certain forms of treatment. Your plan may exclude experimental treatment or treatment not proven medically beneficial. Group health plans place limits on the amount of money they will pay on any particular claim.

 

Q: My group health plan has denied coverage for treatment, saying it is experimental, investigative, or of no beneficial use. What should I do?

A: Contact your doctor's office and explain the problem. The group health plan may need additional information from your doctor explaining the procedure.

 

Q: What if my doctor says I need this treatment immediately?

A: You should contact an attorney familiar with "ERISA." That attorney may seek an immediate court order ordering the group health plan to pay for the treatment.

 

Q: What if my doctor says I need this treatment and the plan will not listen to my doctor?

A: Be persistent. Usually, claims must be processed within ninety (90) days. Any claim denial must be in writing, and must explain the basis for denial of the claim and the steps that you can take to appeal the decision. Your appeal must be in writing. Be sure to keep a copy of the letter. If the group health plan makes an initial denial of your claim, you may want to contact an attorney familiar with "ERISA" immediately. The reason for this is that some courts only will consider evidence the group health plan had before it during the appeals process.

 

Q: What if the group health plan denies the coverage after I have gone through the appeal process?

A: The American Cancer Society funds experimental programs. Call their Cancer Response System at 1-800-ACS-2345. The National Cancer Institute maintains information on experimental treatment programs, clinical trials and new cancer treatments. Call 1-800-4-CANCER. If that fails, you may want to contact an ERISA attorney to consider suing.

 

Q: My group health plan has denied my claim, contending I have a "preexisting condition." What is a preexisting condition?

A: Many group health plans define a preexisting condition as any condition for which you sought treatment, or should have sought treatment, during a specified period before the plan began covering you. Most group health plans have a preexisting condition clause saying that, for a certain period in the future, it will not cover any preexisting condition. After the plan covers you for the required length of time, it will cover your preexisting condition. You may contest the denial of a claim that the plan says is preexisting, just like you can contest other denials.

 

Q: Our doctor says a family member requires round-the-clock home nursing services. My group health plan covers skilled nursing care. My group health plan says the care is custodial care not skilled nursing care. It refuses to pay. What is custodial care?

A: This is a common question of families with a seriously ill member. A court found that constant nursing attention that included restraining the patient, inserting a catheter, deciding when to administer a prescription drug, closely monitoring her for malnutrition and dehydration and attending to her pressure sores was not custodial care.