The “Plan Administrator” is the legal entity who actually establishes the insurance coverage. Often it is the employer who is making the insurance available to employees, their dependents and/or retirees. But Plan Administrators can also be unions or trusts of varying types (e.g. union representatives and management personnel working in tandem). Employer-based health insurance is either going to be “fully insured” or “self-insured” and that distinction can often be critical to a patient seeking an appeal of a denial of treatment.
We want to help you on your road to better quality of life by getting your insurance denial overturned
Plan administrators have a “fiduciary duty” to manage the plan in a way that is in the best interests of everyone, including patients who are denied treatment. While the plan administrator might delegate some of those responsibilities to other entities or organizations (usually called claims administrators or third-party administrators), most frequently the Plan Administrator retains the “final word” on whether claims get approved and they have to use that power wisely, even if it sometimes means using their discretion to overturn a denial.
We help many patients fighting denials to seek a review by the Plan Administrator and this often leads to treatment approvals that have been denied by the insurance company, administrator and even an external reviewer. The Plan is required to ensure a full and fair review of denied claims and is able to approve cases where others don’t have the power. We analyze every situation and understand when the Plan might become the patient’s best chance of winning and, like the IRO process, we are constantly setting your case up to be in the best possible position to get approved by the Plan itself. Doing that makes the difference between you having the surgery or treatment you need or not having it.
601-C East Palomar Street #480 Chula Vista, California 91911 Tel - 877-992-7732 Fax - 844-384-9199
I just wanted to update you and let you know how much we appreciated your help in getting us this approval. My wife had the procedure done in October and has been doing great. Already she has lost weight and her sugar counts are stable and doing fine. The Doctor has taken her off Insulin and High Blood Pressure medicine as a result. She feels real good on the progress she made so far. Once again, thanks for all your help.
I hired them for my appeal. They were great and I was approved a week after submission and my case was not an easy win. I was a revision case and Walter’s appeal letter brought tears to my eyes.
Thank you so very much for this wonderful letter of request. I honestly regret not contacting you when I was initially denied. I am just flabbergasted at the detail and the evidence based references provided. WOW!!! I deeply regret not knowing you existed. You really take the WORD advocacy to a whole new MEANING. Words cannot describe how satisfied I am to see such documentation and how thankful I am for your help. Thank you!
Thank you very much for your quick reply and the helpful tips on what should be done. I will proceed as you recommended and contact you again should I need additional assistance. I appreciate knowing that there is someone out there that is willing to fight to help me have a better life. You need to know how much just just the words in your email mean to me. Thanks again and have a wonderful new year!wing that there is someone out there that is willing to fight to help me have a better life. You need to know how much just just the words in your email mean to me. Thanks again and have a wonderful new year!
Didn't Have To Retain Us!
I want to almost cry after seeing what you have done and going to the ends of the earth in defending my efforts and struggles. I want to thank you so much (the both of you) for all of your efforts. It has really meant the world to me.
Thank you. I’m so emotional right now! You guys are helping me change my life. When everyone told me that I would not be approved,you guys made me feel confident that there was a way. I am forever grateful.
Thank you so much Kelley (and Walter!). I so appreciate all you have done for me!!!
I’m so excited to finally be able to move on!
Oh my goodness!!!! Kelley – I can’t say thank you enough!!!! Thank you, thank you, thank you!!!! This is the BEST news ever. I am SO HAPPY! Thank you! Please tell me where/how I can leave you a review. Both you and Mr. Lindstrom went so above and beyond my highest hopes. I am so incredibly thankful. You guys are the best! Calling now to schedule the surgery!!!
Dear Walter and Kelley: Today is the 1-year anniversary of my lap-band surgery. To date, I have lost 67 pounds and I am in the best shape of my life – I don’t remember a time that I weighed as little as I do now, not even in high school. The time you spent appealing my case was invaluable and absolutely life-changing for me, and I just want to let you know how very much I appreciate all the work you put into it on my behalf. I am thankful beyond words! God bless you!
I wanted to take this opportunity to thank you for taking the time out of your day to update me as well as fighting for me to get this operation. I can’t express enough the joy that it brings me to have such wonderful people at my back when I most need them. I know that this is not final but I still thank you from the bottom of my heart.