When an insurance claim is denied in Pennsylvania, the first thing to determine is whether the plan falls under the Employee Retirement Income Security Act. This act, passed by Congress in 1974, allows companies to self-fund insurance programs. This means the company pays for an insurance claim out of their own funds and claims are not paid from a separate insurance company. It can be confusing, however, because companies often use a network such as Blue Cross and Blue Shield to handle the claims even though the company is paying out of their own funds.
In most cases, if an ERISA claim is denied, you must appeal to the plan administrator or insurance company before filing any type of lawsuit. This is because most ERISA plans require you to exhaust all administrative remedies before going to court. The plan administrator must provide you with a written notice explaining why your appeal was denied and that you have six months to file an appeal. You must also be provided any evidence that is material to your claim and notify you what industry experts they used to make the decision.
Your doctor can act as your authorized representative in an ERISA appeal which will require you to sign an assignment of benefits as well a the Assignment and Designation of Authorized Representative. This will allow your doctor to gain access to the information they will need to file an appeal which should include a request for access to all documents, the right to copies of the plan’s Summary Plan Description, the right to appeal on the patient’s behalf and the right to have a qualified health care professional review the information.
Although your doctor may be well aware of your medical history and the reasons the claim should be covered, they may not be well versed in the administrative requirements. For this reason, it is important that you discuss your case with other professionals.