What Happens if My Request has been Denied by my Employer or Union?
As you and I noted on an earlier page, some policies may be funded by your employer or union. If you are requesting a service or treatment which your employer or union has not included as a policy benefit, you may receive a denial from the insurance carrier. The denial isn’t based on medical necessity; rather, it is based on the fact that they cannot approve a service/treatment that is not part of your plan.
If you request reconsideration, your insurance carrier can submit your request on your behalf to your employer or union. If your union or employer continues to deny your request you will be directed to follow the guidelines for appeal through Employee Retirement Income Security Act (ERISA).
Your employer is required to meet certain Federal guidelines. If they are found to be out of compliance by denying your care, your request may be approved. If, however, they are in compliance with the care they provide, they may not be required to provide the services you are requesting.
Here's an example:
Let's imagine that you are requesting a gastric bypass. Because of your weight, you are now diagnosed with Type 2 diabetes and hypertension. You have pain in your knees and may require joint replacement in the future. If you were able to lose the weight, this could help resolve your Type 2 diabetes and hypertension. This could also relieve some of the pressure on your knees.
Your doctor submits the request to your insurance carrier, noting that you meet the community standard (a BMI/Body Mass Index of 30 or greater). You both receive the denial letter stating that "this is not a covered benefit". You submit a request to your insurance carrier requesting reconsideration of the denial as you believe the surgery would be more cost effective in the long run if you factor in the cost of treating complications from diabetes, hypertension and joint replacement.
Unfortunately, your insurance carrier has been informed by your employer that, under no circumstances, will they cover the cost of a gastric bypass for any employee.
A letter is issued at the appeal level providing you with information about ERISA. You contact the appropriate government office and are informed that the procedure requested is not one which must be provided by your employer.
In this case, the denial is upheld.
Return to DENIED, Now What Happens?