I recently obtained several successful recoveries against the ILWU-PMA health plan which is the large, self-insured benefit plan for all longshore workers and their dependents. Like all self-insured plans, this one is governed by the federal ERISA law. Many healthcare providers, including surgeons, surgery centers, chiropractors and physical therapists have had their legitimate claims denied over the past three years as the Plan cracked down on allegedly fraudulent claims.
Here are tips for you to maximize your efforts to obtain payment on your healthcare claims:
Request a Full and Fair Review of your claims.
ERISA requires that you first exhaust your administrative remedies. To do this you must request, in writing, a “full and fair review” of your claims by the trustees. Your claim is deemed denied if you do not hear back within 30 days of your appeal. The Plan trustees have to respond to you within 30 days of your request, unless your documents are incomplete or they request more time in writing.
Obtain a Copy of the Plan’s Grievance and Appeal Provisions.
Every plan participant is entitled to obtain a copy of this procedure. It usually is contained in the Plan Summary Plan Description which is given (or should be given) to each insured, or it could be a separate document. Follow the procedures, in writing, contained in this document.
Request A Review By the Coast Arbitrator.
If your claim still is not resolved at the trustee level, you can request a review by a Coast Arbitrator. Do this in writing. The expenses of the Arbitrator are paid by the Plan. You have the right to an arbitration within 15 days of the decision by the trustees (although it usually is much longer). I have found that this process works fairly. There is usually just one arbitrator for all healthcare claims. You will be given an opportunity to provide an Opening Statement and to respond to briefs by the Plan lawyers. Definitely respond with any documents that have not previously been submitted and argue your case. You can waive your right to an in-person meeting.
Hire An Experienced Lawyer Who Knows ERISA.
You can hire a representative, called an “authorized representative” to do all of this for you. That person can be an attorney. The Plan trustees will have lawyers involved in the arbitration. Separate lawyers will represent the Union Trustees and the Employer Trustees.
Sue Under ERISA.
If this still does not resolve your claim, you have the right to sue under ERISA. If you prevail, you can recover your attorneys’ fees and the healthcare claim will be paid. The ERISA claims regulations are found at 29 Code of Federal Regulations 2560.503-1.
In sum, do not give up. Find out your rights and enforce them. If you have a good claim, it is likely it will be paid. ROBERT AMADOR, ESQ. (310) 792-7400.