Self Insurance - Vague Summary of Benefits

[linda01]

What is the name of your state?What is the name of your state? Illinois

I am covered by my husband's employer, and they are a very large company with is self-insured. They use a third-party administrator.

In the Summary of Benefits, I have full coverage for maternity benefits. In another section, it says that "Fertility Services" are not covered.

Now, how this all affects me. Four years ago, our first pregnancy was diagnosed in the fifth month with a severe, fatal chromosomal disorder, and I lost the pregnancy. At that time, my husband & I were both genetically tested, and neither of us are carriers of any genetic/chromosomal defects that could cause such a problem. Since then, I have had two consecutive miscarriages.

My doctor wants to send me to a Reproductive Endocrinologist that specializes in recurrent miscarriage to find out if I may have an autoimmune disorder, or to look for other problems that may be attacking the pregnancy after conception.

I called the 3rd party administrator (confused by the "Fertility Services" section) to find out if this would be covered. They will not define "Fertility Services" for me, and tell me that recurrent miscarriage is considered Infertility and it is not covered. Medically speaking, Infertility is defined as an inability to concieve after having unprotected sex for 12 months or more. Obviously, my problem is not an inability to conceive. They refuse to cover any diagnostic tests/treatments to determine the underlying cause of my miscarriage problem, because they say that they are the same types of tests/treatments used to diagnose/treat infertility.

To me, this is like saying, "Well, we don't cover heart transplants, and so we can't cover any cardiological testing since it is the same type of testing to diagnose the need for a transplant."

I have tried to obtain a detailed summary of benefits, but they will not send me anything aside from the general summary that is listed (2 pages long) online, but when I call, they keep referring to another benefit summary, and say things like "Well, on page 45, it says that Genetic Testing is not covered in any circumstance." I love to see this document with at least 45 pages!

Are there any legal avenues that I could take to obtain a full description of my plan, in writing? Also, since I have full maternity coverage, and I'm obviously a high-risk patient, are they required to cover items that my doctor feels are medically necessary to maintain and treat the pregnancy?

During my previous pregnancy, my doctor wanted to put me on a hormone therapy in hopes of saving the pregnancy, but my insurance company refused to cover the medication saying that it is a drug used for infertility....even though I was already pregnant!

Any thoughts?!?

Thanks!
Linda

 

[cbg]

"I love to see this document with at least 45 pages!"

The full benefit plan is probably a couple of hundred pages if not longer. I've seen Summary Plan Descriptions that run longer than 45 pages. I don't know why you'd think the entire plan document would be less than 45 pages.

Are there any legal avenues that I could take to obtain a full description of my plan, in writing?

I could be mistaken; it's been a couple of years since I dealt with this aspect of Benefits. But I believe that they've fulfilled their legal obligation to you as long as they've provided the SPD, which it would appear that they've had. One of the reasons is provided above. The sheer size of the full plan description. You can certainly call the US DOL and ask them if they are required to provide you with a copy of the entire document.

Also, since I have full maternity coverage, and I'm obviously a high-risk patient, are they required to cover items that my doctor feels are medically necessary to maintain and treat the pregnancy?

No. Insurance is a contractual benefit. The law does not require them to cover anything that your doctor finds medically necessary, only what the contract says they will cover. They have no legal obligation to cover items that the contract says are excluded.

 

[linda01]

Thank you for your advice.

Just to clarify, I fully believe that the full Plan Description is much longer than 45 pages....but I am bothered by the fact that I am not able to see it, (even though I am paying for the coverage).

"No. Insurance is a contractual benefit. The law does not require them to cover anything that your doctor finds medically necessary, only what the contract says they will cover. They have no legal obligation to cover items that the contract says are excluded."

As you said, it is a contractual benefit....why is it then, that I am not permitted to read the contract? I would like full descriptions of what is excluded in the contract.

Thanks for the advice to call the Department of Labor. I'll give it a shot, see what they say!

Thanks again.

 

[cbg]

why is it then, that I am not permitted to read the contract?

I don't know for certain that you aren't. But in any case, you are not a party to the contract.

 

[linda01]

"I don't know for certain that you aren't. But in any case, you are not a party to the contract."

Who, then, is the contract between? There is no insurance company...the company itself pays my claims.

 

[cbg]

The insurance plan itself is a contract between the adminstrator (who is almost certainly an insurance carrier or broker) and the employer. "You will manage the claims adminstration of this policy and we will pay the claims". The adminstrator and the employer determine what will be covered; then the adminstrator processes the claims for the employer and the employer pays what the administrator says was covered under the terms of the plan.

The employees are under the umbrella of the employer as regards the employer, but you don't have the full power of a separate party. For example, you don't have negotiating power. You don't have the authority to determine what will or won't be covered and you don't set the rates. That is all established between the administrator and the employer.

 

[linda01]

The mud is getting clearer....thank you!

I did learn, after much web-searching, that ERISA does require that if a company is self-insured, they are required to give you a full copy of the contract in it's entirety. ERISA, unfortunately, is a double-edged sword, as it gives any self-insured employer exemption from any state insurance mandates. Illinois does have a state mandate that requires insurance companies to cover Infertility expenses.

Thanks for your help. I'm still questioning the administrator's approach to considering a diagnosis of Recurrent Pregnancy Loss the same as being diagnosed as Infertile, but that's another row to hoe after I am able to see how things are defined within the contract.

Thanks again for your help!

 

[somarco]

My doctor wants to send me to a Reproductive Endocrinologist that specializes in recurrent miscarriage to find out if I may have an autoimmune disorder, or to look for other problems that may be attacking the pregnancy after conception.

I called the 3rd party administrator (confused by the "Fertility Services" section) to find out if this would be covered. They will not define "Fertility Services" for me, and tell me that recurrent miscarriage is considered Infertility and it is not covered. Medically speaking, Infertility is defined as an inability to concieve after having unprotected sex for 12 months or more. Obviously, my problem is not an inability to conceive. They refuse to cover any diagnostic tests/treatments to determine the underlying cause of my miscarriage problem, because they say that they are the same types of tests/treatments used to diagnose/treat infertility.

A reproductive endocrinoligist does treat problems related to pregnancy, including infertility. Fertility treatments may in fact be a non-covered item (as they normally are in most benefit plans). Obviously you represent a high risk and coverage under the plan for any treatment related to pregnancy would most likely fall into a "gray" area . . . even if you had access to the full SPD.

Since you apparently want to pursue testing with the endocrinologist, why not do so at your own expense, then file the claim afterward? If the claim is properly coded in such a way as to be deemed a covered item then it will be reimbursed. On the other hand if the CPT and ICD coding falls outside the contractual provisions it will be denied.

It seems that you are attempting to dictate to the employer what should and should not be covered under THEIR plan. And yes, a self funded plan falls within ERISA regs and is exempt from any state mandates. That is precisely why many employers opt to self fund, to escape the (sometimes ridiculous) mandates of the state legislature.

Your issue with the TPA is more of a coding issue and not so much a matter of what the SPD says.

BTW, your SPD also spells out your rights to appeal.