VIDEO ON MSN MONEY

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Dec 23, 2011 4:27PM
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More bad advice from MSN on insurance matters.  Health insurance is most often provided under an employee sponsored plan and, thus, governed by the Employee Retirement Income Security Act (ERISA).  What most people don't understand about ERISA is that it gives an "administrator' of the plan discretion to determine if a procedure is covered or not.  If you do end up suing the Plan for coverage, the Judge does not determine if the administrator was write or wrong, only whether the administrator abused his/her discretion in denyimg the coverage.  Thus, an administrators decision could be wrong and the coverge denial will still be upheld - so long as the administrators decision was not "arbitrary or caprecious."

Also, the trial does not allow the insured to submit evidence or call witness (except in limited circumstances).  Instead, the judge "reviews the record" - i.e. - what you submitted in support of coverage vs. what the insurance company relied on in making its determination.  Who do you suppose has its case better documented? The insurance company, of course. 

And, the insurance company will set you up for failure in this regard by telling you that the appeal process (which is the record on review) is a simple process - all you have to do is requst a reconsideration of the decision.  When your appeal is denied, therefore, you have nothing to support your case when the judge makes his decision.

If you have been denied coverage, and the costs of treatment are significant, seek the advice of a lawyer who is experienced in ERISA law immediately.  Waiting until the appeal process has been exhausted will severly reduce your chance of a successful outcome.

 

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