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Health insurance denial for treatment and "self-funded" plan rules?

My doctor tried to get preauthorization for treating a medical condition of mine more than nine months ago. My insurance stubbornly denied it time after time after time. Between these ?time after time? periods, the requests were lost in the mail (if you believe that), papers were ?misplaced? by them, and there were delays because of practically every little thing. Eventually, my case went to an external review board that ruled in my favor, over-turning the plans denial; the insurance has to pay for my treatment now. This ruling in my favor came just last week, the same week that my coverage with this health plan ended as a result of my COBRA continuation coverage expiring. I believe my insurance should still have to pay for the treatment, because I would have had the treatments months ago, when I was covered, if it weren?t for the insurances negligence and incompetence.

Public Comments

1. It doesn't work that way. If you would have had the treatment the months ago, now it would cover it. If you wait until the coverage expires, they're REALLY off the hook. If you need treatment - you get the treatment, and worry about getting the insurance company to pay for it later. If you can wait 18 months, you can wait another couple years. If you needed it then, you should have gotten it then. I'm sorry. You could ask the insurance department or the external review board to make them cover you, but I don't think you'll win this one. If it WAS medically necessary, it should have been done already.
2. Nope, doesn't work that way. Your insurance company covers charges that are incurred on dates when your policy is valid. So, if you had actually had the service done while you were waiting for the decision to be overturned, then the insurer would now have to pay your doctors for it and/or reimburse you. On the bright side, you can use all of that documentation to demonstrate to your next insurer that they should cover the services. You can't force the insurer to pay for something that happened after your coverage was terminated, unfortunately. Since you mentioned that your plan is self-funded, I'll point out that there's not point in complaining to the Department of Insurance in your state...the Department of Insurance doesn't govern self-funded plans. You'd have to file an ERISA complaint through the federal government.
3. u find some details on this http://www.insuranceplan4u.com/health/
4. Many insurance companies will deny a claim simply to make you go away. In a self funded situation it may be that the employer wanted to stall until your COBRA ran out. My suggestion is that you contact an attorney regarding this. You have suffered needlessly for too long and the company has successfully kept your claim at bay. They have benefited by keeping their contributions to the fund at a minimum. This is why many self funded companies seem to have a much younger set of employees as well. Younger people usually have much less need of serious health coverage. I've bookmarked this site... http://www.123thebest.info/go.php?link=insurance Good Luck.