My employer hired a third party and I cannot contact my insurer. What are my rights?
A plan can route calls through an administrator or navigator, but it cannot remove your right to a written determination, the plan document and an appeal decided within the legal timeframe. Put every request in writing to the claims administrator named in the Summary Plan Description, copy HR, and use the plan's own deadlines.
What to do, in order
- Step 1
Find who actually decides
Ask for the Summary Plan Description. It names the plan sponsor, the claims administrator and who decides appeals. A member-contact vendor is usually neither; address written requests to the administrator named in the SPD, through the vendor if that is the only channel, and keep proof of delivery.
- Step 2
Insist on what the law gives you
A written denial with the specific reason and plan provision; the plan document and any clinical criteria used; a decision on a pre-service appeal within 30 days and a post-service appeal within 60 days on ERISA plans; access to the claim file. The vendor arrangement changes none of this.
- Step 3
Convert a stall into a decision
If a request is stuck past the plan's timeframe, write that the plan has failed to decide within the required period, that you treat the request as denied, and that you are appealing. That makes the delay an appealable event and, on ERISA plans, can deem the internal process exhausted.
- Step 4
Escalate outside the plan if needed
Self-funded plans: the U.S. Department of Labor. Insured plans: the state insurance department. Check which you have before you write.
The deadline that applies
ERISA plans must decide urgent pre-service claims within 72 hours, other pre-service claims within 15 days (one 15-day extension), post-service claims within 30 days (one 15-day extension), and appeals within 30 days pre-service or 60 days post-service (29 CFR 2560.503-1). If the plan misses these, the deemed-exhaustion rule applies. Your own appeal window is at least 180 days from any written denial.
Calculate your date →Documents to gather
- The Summary Plan Description
- Your ID card and the vendor's contact instructions
- Every written request you sent, with proof of delivery
- Any written response, or a note of the date the timeframe ran out
Go deeper
Related questions
Can I call the insurer directly anyway?
You can try, but if the contract routes members through the vendor they may refuse. Writing to the administrator named in the SPD is the reliable route.
Is the vendor liable for delays?
The plan is. Delays by its agents are the plan's delays.
What should the first letter say?
Request the SPD, the claims administrator's address, and a written determination on the pending request by a named date.
Sources
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