An important appeal option which should not be ignored!

The role of your Plan Administrator

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

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