Supreme Court Comes Through For Obamacare!

If you are interested enough in the topics I discuss in this blog, you probably already know that the Supreme Court, in the case of King v. Burwell, upheld the health insurance subsidies that are a key part of Obamacare.  In my civilian life as a liberal democrat and strong supporter of President Obama, I am happy with the decision.

But, as a Connecticut ERISA lawyer, I am happy for what the decision means for my clients.  For all the problems with insurance that I discuss in this blog, insurance is a good thing, and good insurance is a great thing!  Obamacare, or more formally the Affordable Care Act, is achieving its goal of increasing the number of insureds, and making sure that insurance is more likely to cover the expenses from a serious health condition.  You may need my help, or another ERISA attorney, to appeal an insurance company's denial of a medical claim.  I would rather have that fight, though, then try to keep a hospital from foreclosing on your house for unpaid medical bills. 

The Act does other good things.  For years prior to the Act, I had clients who used up their COBRA, or couldn't afford COBRA, and had preexisting medical conditions that prevented them from buying private insurance.  Or, once they lost their jobs, they had no way of affording health insurance, but now, they can get subsidies on the health exchanges.  

There are problems with the law, of course. and any program as huge as Obamacare will have problems with implementation.  But with the Supreme Court's decision today, the question of the legality of the Act should be over, and opponents and supporters can work together to make the law more effective and fair.  

Health Insurance Doesn't Always Protect You From Big Bills

The New York Times has a post today on people who have health insurance, but are underinsured, defined as paying more than 10% of income towards medical bills.  One of the reasons people who are insured still have big medical bills is that the insurance company denies medical claims that they should pay.  They deny claims for many reasons, including that the requested treatment is not medically necessary, or is experimental, or the requested treatment is out-of-network and the insurer claims equivalent treatment is available in-network, even though your doctor disagrees.   This can occur with both private insurance, and insurance through an employer that is governed by ERISA

If an insurer does deny on a claim on these basis, you do have remedies that can keep you out of the ranks of the underinsured.:

• You can file an appeal with the plan.  This is a crucial step.  You cannot pursue any of your other remedies until you file the appeal with the plan.  Also, it may be your only chance to submit information in support of the appeal.  Having an  experienced Connecticut ERISA lawyer to handle the administrative appeal can help to make sure you have all the information in the file to succeed at the later appeal levels.  
• For appeals of denied health insurance claims in Connecticut, you can file an appeal with the Connecticut Department of Insurance. .  Here is a link to a guide to the process.  The Affordable Care Act requires states to establish procedures for appeal of denial health insurance claims, so there should be a similar process in your state if you are not a Connecticut resident.  
• If these don't succeed, you have the option of pursuing your claim in court: in federal court for ERISA claims arising from plans established by your employer; or state court if you purchased the plan directly.  Whether you have a good claim in court depends largely how complete your prior appeals were, so be careful with the appeals!

Insurers do not always pay the claims they should pay under the policy.  By effectively appealing the decision, you can increase the chance you will avoid the big bills that will make you underinsured.  An experienced employee benefits attorney in Connecticut or your state can be a big help in making this happen.

Denied Health Benefits under an ERISA Health Insurance Claim? Obamacare Can Help

President Obama’s health care law, the Patient Protection and Affordable Care Act (“ACA”), also known as Obamacare, requires health insurance claims to provide for external review of many types of denials of health benefit claims under group health insurance policies governed by ERISA.  An explanation of the final rules can be found here. 

For more than thirty years, ERISA health insurance plans had to provide for an internal administrative review of health benefit claim denials, a process that a claimant had to pursue before bring suit in federal court for a health claim denial.  The ACA added a significant improvement in the existing, pre-litigation review process for ERISA health plan denials.  It requires plans to offer an external review process for health insurance benefit denials, conducted by an independent third party.  The external review process is available when the denial involves application of medical judgment such as medical necessity, level of care, and experimental or investigational treatment, and whether the health care setting (out-patient, or intensive out-patient, or residential treatment) is appropriate.  I have found the process particularly useful in appealing denials of residential treatments for eating disorders or substance abuse treatment for teens.  The external review process occurs after you have exhausted the plans administrative appeals.  In addition to the claim file, the external review will consider new arguments and documents you submit with the request, so the request should be carefully completed to make it as effective as possible.  

In my Connecticut ERISA appeal practice, I have found the process particularly useful in appealing denials of residential treatments for eating disorders such as bulimia or anorexia or drug or alcohol substance abuse treatment for teens.  Connecticut does not have facilities offering residential treatment in these areas, so doctors and parents want to send teens to out-of-state programs.  

Connecticut has been a leader in implementing the ACA, so it is not surprising that Connecticut has established a good external review process.  The external review process is conducted by the Connecticut Department of Insurance.  Click here to go to the site.   A Connecticut ERISA benefits lawyer, familiar with Connecticut’s procedures, can be a big help in preparing an effective request for external review.

An important thing to remember about external review is the deadline is 120 days after the denial.  The regular time to appeal ERISA denials is either 60 days, or more commonly, 180 days, so make sure you, or your ERISA attorney, are aware of the difference.

Because of the external appeal process established by the ACA, at least with health insurance claim denials, the insurance company does not have the last word before you have to bring suit.