How to Appeal a Federal Insurance Claim Denial

This article was originally published here

The Federal Employees Health Benefits Program (FEHB) can aid you and your family in meeting your healthcare needs. Federal employees, retirees, and their dependents have access to the most comprehensive health care options in the country.

Federal insurance claims can sometimes be denied. Denial occurs when your federal employment insurance program informs you that your medication or therapy will not be covered. It is quite irritating and frightening if you are obliged to pay for the entire cost of treatment. However, you can fight against the denial of a federal insurance claim. 

Initially, examine if the service is included, restricted, or exempted in your plan’s brochure. Further, go through the section of your brochure that deals with the disputed claims. Concisely, this section will instruct you to contact the plan and clarify the reasons why you believe the services should be covered (consider the appropriate brochure coverage provisions). You will also be instructed to request that the plan review your claim. 

If the plan denies the claim once more, read the plan’s conclusion letter carefully and double-check your plan’s brochure. If you continue to disagree with the plan’s judgment, the disputed claims portion of your brochure will explain how to contact the Office of Personnel Management and request a claim reassessment.  

The Office of Personnel Management (OPM) is adopting provisional measures to amend the Federal Employees Health Benefits Acquisition Regulation to include a new contract provision (FEHBAR). The clause clarifies for both FEHB carriers and covered people the conditions in which OPM may decide about a covered person who requests OPM to reconsider a health benefits plan’s denial of a claim if the plan has either confirmed its denial once the covered individual requested reconsideration or has failed to answer to the covered individual’s request for reconsideration as provided by OPM’s regulations.  

Claimants may seek court review of benefit denials under the FEHB program in certain instances, according to the provision. The objective of these interim regulations is to make it clear that covered persons who want to file a legal claim over rejection of an FEHB benefit must do so through OPM. The interim regulations also define the administrative review procedure that must take place before legal action may be taken in court. 

In most cases, OPM will respond to your inquiry within five days. OPM will offer you a final response within 60 days once the evaluation is completed. If it requires more time or you need to do more–for example, email more information–they will contact you within 14 business days of receiving your request and tell you what you need to do next, if anything. The Office of Personnel Management will not decide over the phone until the review is finished and a written copy of the final decision is delivered. 

If you are unhappy with the outcome of the OPM review, you may be entitled to file a lawsuit in federal or state court, depending on your state’s rules. If required, seek legal advice. 

If your claim is refused, you have 60 days to request reconsideration, and the carrier will answer within another 60 days. Suppose the reconsideration judgment denies the benefit again. In that case, you have 60 days to submit an appeal with a committee comprised of persons appointed by the John Hancock life insurance business, as well as others, if mutually agreed upon with the OPM. Within 60 days, the appeals body will make a ruling. 

If the committee sustains the denial, you have the option of requesting an appeal to an independent third party chosen by OPM and the carrier. The request would have to be submitted within 60 days, and a decision would have to be made within another 60 days. 

You may seek judicial review of a final rejection of eligibility for benefits or a claim in federal district court after exhausting this appeals procedure. The amount of compensation would, however, be restricted to the benefits that would have been receivable. Actions against the Office of Personnel Management or the third-party adjudicator are also prohibited, as are suits based on state or municipal law or regulations. 

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M. Dutton and Associates is a full-service financial firm. We have been in business for over 30 years serving our community. Through comprehensive objective driven planning, we provide you with the research, analysis, and available options needed to guide you in implementiong a sound plan for your retirement. We are commited to helping you achieve your goals. Visit us at M. Dutton and Assoiciates.COM. Tel. 212-951-7376: email: [email protected]