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U.S. Department of Labor
Employee Benefits Security Administration
Updated: August 2003
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If you are an employee
or family member of an employee who receives health benefits from a health
plan provided through employment in the private sector, a Federal law, the
Employee Retirement Income Security Act (ERISA), protects you. Among the
protections, ERISA sets standards for administering these plans. Those
standards require plans to give you important information about the plan
and to have a fair process for handling benefit claims.
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Below
are steps you should take to file a benefit claim and what to do if your
claim is denied. It is especially important to know your rights under your
plan and the law if your benefit claim is denied. |
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The
first step you should take - even before you are ready to file a benefit
claim - is to carefully read your plan’s summary plan description. This
is a document which your plan administrator must furnish to you after you
join the plan. You can also request a copy from your plan administrator.
The SPD gives you a detailed summary of your plan - how it works, what
benefits it provides, and how they may be obtained (the process for filing
your claim). The summary plan description is also required to describe
your rights and protections under ERISA. |
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ERISA requires every
plan to have procedures for filing a claim and to tell you what those
procedures are. As noted above, this information must be included in the
summary plan description.
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All
plans have rules governing what benefits they offer and how to apply for
them. For example, some plans may require you to file a claim (seek
authorization) before you can receive medical treatment. Some plans may
have special rules for urgent care. For other plans, you must submit
a claim for reimbursement after receiving and paying for the care
yourself. |
To
avoid a delay in processing your claim or a denial of your claim, you
should follow the steps outlined in your plan’s summary plan description
when filing your claim. If you cannot find the steps, or if you cannot
understand them, you should consult your plan administrator or contact the
Department of Labor’s Employee Benefits Security Administration (EBSA)
for help in understanding your rights. |
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Your
plan’s claims procedure should state the time within which the
plan must provide you with a decision on your claim. Be sure to look for
these in your SPD. When you submit a claim to your plan, note the date and
keep track of the time as you wait for a decision. Some plans may have
different time periods depending on the nature of the benefit claim - such
as whether the claim is for urgent care and whether the claim is filed
before medical care is received or after. Some plans’ procedures allow
the plan to extend the time period. Your plan’s claims procedure should
provide for the plan’s notification to you of the plan’s decision on
your claim for benefits. If you do not get a response from your plan
within the specified time period, contact your plan administrator. |
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Your plan may deny a
claim for many reasons. For example, you may not have met the plan’s
annual deductible; the requested treatment may be something the plan says
is not covered or not medically necessary; or you may not have filed
enough information for the plan administrator to process the claim. Look
for the reason and other information provided in the notice of denial so
that you can determine if you want to appeal the decision.
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When you are notified
that your claim has been denied, your plan administrator also must tell
you how to appeal your denied claim for a full and fair review. Your plan
will specify the number of days you have to file your appeal and may
provide for extensions of that time period. When appealing a benefit
denial, be sure to include any additional information or evidence
supporting your claim or required by your plan’s procedure, and get it
to the specified person and address within the permitted time period.
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Your plans’ claims
procedure should also specify the time period for the plan to make a
decision on your appeal. Note the date when you submit your appeal and be
aware of this waiting period. The waiting period for decisions on appeals
may also be different depending upon the type of claim that was initially
filed - such as whether it involves urgently needed care or whether the
claim is filed before the medical care is provided or after.
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When the decision is
made on your appeal, you must be notified of the decision. If your claim
is denied, you must be told the reason and the plan rules upon which the
decision was based in writing in a manner you can understand. If you do
not receive notification of the decision within the waiting period
provided for in your plan, you can assume your claim has been denied after
it was reviewed.
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If you disagree with
the final decision on your appeal or if your plan fails to make a timely
decision, you have the right under ERISA to file suit in court to get your
benefits. The plan’s explanation of your denial should describe this
right. You also may wish to get in touch with the Department of Labor’s
Employee Benefits Security Administration concerning your rights under
ERISA.
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As noted above, it is important that you know your
plan’s claims process. If you fail to follow the plan’s process,
including meeting required deadlines, your ability to challenge the
plan’s decision in court could be affected. |
If your plan’s procedures do not give you the rights
provided for under ERISA, or if your plan fails to follow its procedures,
you may have the right to bring an action in court to enforce your rights. |
For further information on your rights and
responsibilities under ERISA, contact EBSA’s toll-free publications
request number at 1.866.444.EBSA (3272). You can view available
publications on the EBSA Web site at www.dol.gov/ebsa. |