ERISA ????

[Kim]

Hello
Well I got the letter in the mail today and once again I was denied SIGH. The letter stated that I do have the right to appeal again to an independant review away from the insurance company. I also have the right to file with ERISA.
I am not trying to be too negative but wonder how independant the opinion can be when they are paid and procured by the insurance company themselves?
I am interested in filing a complaint or whatever with ERISA and was wondering if anyone here has experience with this and could possibly help me walk through it?
Thanks in advance

[spotty14]

The Dept. of Labor website has ERISA information.
www.dol.gov

What type of claim do you want to file?

[BRENDAWY]

Have filed a claim against your insurance company with the insurance commisioners office? You could file for failure to provide benefits. Contact senators. Senator Enzi is a good one. I can email you his phone number. His office has been very helpful. BrendaWy

[Kim]

I plan on filing a claim both with ERISA and the State Insurance Commisioners office for failure to provide benefits for my surgery. I have contacted both my senators and some representatives. I did get one response back telling me that insurance is handled on a state level to file the complaint with the office above.
I am going to research some more on ERISA and see exactly how I want to proceed. It states in my policy book and in the letter I received that I can file a court case in either state or federal court at any time protesting thier denial to my coverage.
Brenda yes if you can email me with Senator Enzi's phone number I would appreciate it. Feel free to PM me
Kim

[Kim]

Update
I called the Federal office in Atlanta today and they basically told me I have the right to fight the insurance company's denial of benefits in federal court. I will have to hire an atty. I dont know what the expense would be. They are sending me out a booklet that will explain to me how to file a claim with ERISA etc. I will post once I get this in case the info is needed by someone else.
I am in the process of filing a complaint with the State Ins Commisioners office due to this. I figure it cannot hurt.
I have also called the Medical Mgr to see what the drs credentials were that denied my claim. His comments on the denial were laughable in my opinion.
And the battle goes on......................

[Patrick]

Kim,

Good luck with all of this. I don't know how some of you people here find the strength to fight all the people and companies working against you. You guys are truly an inspiration. Thanks for the talk the other day Kim...you are definately on your A game. God speed...

[Kim]

Well bad news sigh. I got the packet from the State Ins Commisioners office and they dont have any jurisdiction over self ensured employee health plans which is what we have. I was directed to the Federal office in Atlanta that handles ERISA issues.
They basically told me my only recourse is to file a suit in Federal Court to dispute this. That means hiring an atty, yada yada yada. I asked the gentleman yesterday why the insurance company has no one to answer to when they do not follow their own policies and procedures set out in our beneifts documents. He had no answer for me but was sympathetic.
This really stinks! There should be someone that the insurance companies have to answer to other than the Federal Courts in a situation like this.
I am not out but I am sinking low in the counts today.

[Dale S]

Kim,

I'd like to provide some advise through a successful viewpoint but it looks like I'm in the same boat. I received my second declination letter on Saturday. I think they're trying to wear me down and the sad part is that they're succeeding.

I will try to appeal a third time before turning in another direction and received a basic outline from a packet of info I requested from DePuy customer service 800-227-6633 (from another post). She was very sympathetic and also gave me the phone number of the DePuy regional rep who primarily deals with payors (ins cos). She has yet to return my calls but maybe she can do something. I don't know, I'm just grabbing at anything I can with too much hope each time.

If I'm reduced to a lawsuit or arbitration, I'll probably pay for the adr's myself and take on the legal system when I'm feeling better and can stand up, literally, for myself.

Wishing us all a lot of luck, Dale

[Kim]

I hear ya Dale. It seems we have no easy or even half way aggravating answers here. If you get any info from the DePuy rep I would appreciate you passing it on to me. I am not up for a legal battle at present and dont have the thousands to spend on it even if I wanted to .
Maybe I can win the lottery and pay for my surgery myself. That looks like my best bet at present

[ans]

Sorry you were denied Kim and you guys are fighting the good fight. Something I think that I will. Best, Allan