employeers responsibility in regards to and employees medical claim

MariaI · May 2003

My company offers it employees medical coverage thru various insurance carriers. The employer pays 95% of the premium. A common problem is that when an employee submits a medical claim for themselves or one of their dependants and it is denied they seek the help of the employer in fighting their claim. My question is ... What is the company's responsibility regarding the employees medical claim (or a claim submitted by one of their dependants) in regards to fighting the insurance company to approve the claim? If there is no legal responsibility what if any disclaimer can I attach to the employee benefits manual explaining the employers obligations?

LindaS · May 2003

The first thing you need to think about now is HIPAA - if you are a large employer you should already have policies and procedures in place regarding how to handle this. If you are a small employer you have until next year but this is one of the examples I have had used in the training sessions I have gone to. Anyway, regarding your question, the employer doesn't have any legal obligations to fight the denial of a claim for an employee. If the employee feels this was denied incorrectly, you can choose to make some calls for the employee but there isn't anything legally required that you do. If you don't feel that this is something you want to engage in, you can simply give them the phone number of the claims office and have them do the legwork but you will have some unhappy employees.

I don't think a disclaimer is necessary since this type of information is usually contained in the SPD - it's just that the employees fail to READ the manual.

MariaI · May 2003

Thank you very much for your help. I still have two more questions.... One is.. We are a 45 person firm is this considered large and if so what are the HIPPA issues I should know and what is the SPD? Thank you again!

mbeam · May 2003

Large is usually determined by the amount spent on your benefits plan relative to health care (at least as memory serves me). Also believe that the dollar amount is around $5,000,000.

Judging from the size of your business only, I would estimate that you would fall into the category of small businesses and have until next April to be in compliance.

SPD's are the plan documents relative to the benefit being offered. These are the detailed explanations about the plan benefits and utilization.

System · May 2003

Dumb question - why doesn't the provider of service file the claim for the ee? Usually at least a one insurance filing is provided by most health care entities. You didn't mention what type of organization your company is. We are a small home health agency (under 50 employees) and had to comply with HIPAA this year because of PHI for patients, as well as privacy requirements for our employees. I agree with other response regarding the phone call. The ee benefit card should have a toll free number on the back for just such a situation. Maybe I am a bad HR person, but that is what I tell the ee when they call - check the 800# on your card and speak with an insurance representative to find out exactly why the claim was denied and take it from there. Also an EOB shouldhave been provided by the insurance carrier to the ee with an explanation - most of the time the amount went toward the annual deductible. If you haven't started HIPAA paperwork yet,I would be happy to share documents with you. If you are interested, please email me at [email]cwinebarger@charter.net[/email].

employeers responsibility in regards to and employees medical claim

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