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
This made my life. Literally. I cannot begin to thank you enough for your expert help in having this over turned for me. I know without your help, it wouldnt have been possible. My surgeon has me scheduled for surgery on Feb 6. I will be sure to stay in touch and let you know how it all goes. I have a lot of hope that I will be able to come off of my insulin pump and have better control with just a few injections. I truly believe this is possible for me, and that my quality of life will be so much better. The work you have done is going to change so much for me. I plan, in turn, to make a difference for many others. Its a pretty great ripple effect, isnt it?
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.
Walter and Kelley,
1 year ago today I had surgery with Dr. Alok Gandhi at Rochester general hospital. I am happy to report that I have lost 120 lbs., off all of my medicine and cpap machine. I take vitamin supplements but everything else is gone. I just wanted to thank you again for your help with CIGNA and wish you both a great day and a very heartfelt “Thank You”.
Mrs. Lindstrom, Thank you for the great news.I will call my surgeon’s office to work out a schedule. I am grateful that they referred me to your office and I will recommend you to anyone who needs assistance.I believe that this result was achieved only through the advocacy of your firm. Thank you very much for all of your effort.
Wishing you and Walter a GREAT 2015 also. You both gave me the tool I needed to get my life back – without the both of you (and your AMAZING team) working on my case I cannot say that I would be where I am today. I APPRECIATE all you did and continue to do for people like me. I continue to spread the word about your advocacy group and all you can help other accomplish if they only make that first call or send that first email like I did. I hope others I have talked to have taken advantage of the help and guidance you can provide. I will sing your praises to anyone who will listen – especially if they have a denial for surgery.
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!!!
I am absolutely over the moon excited right now. I finished my 6 months supervised diet/nutrition with my surgeon’s office back in April, but I was denied when it was submitted to insurance, despite having a BMI of 42 and GERD (they denied it and said GERD wasn’t one of their approved co-morbidities, and my insurance plan requires a co-morbidity regardless of BMI). I immediately contacted Lindstrom Obesity Advocacy and began the appeals process with them. Within a month of them sending in my (wonderfully written) appeal letter, I just received a call to let me know that United has approved me for surgery and has provided their office with the approval and authorization number. . . . I am beyond excited! This is actually happening!!
I just called my doctor’s office and the scheduler was absolutely amazed the denial got overturned! She said she has done tons of appeals for patients and it doesn’t ever usually work out this way. I can’t speak highly enough of Kelley and the Lindstrom group.
I had to go to external review but I’m now APPROVED for revision from Band to RNY!!!! I can’t say enough positive things about Kelley & Walter at Lindstrom Obesity Advocacy. If you find yourself stuck with denials from insurance companies, I highly recommend them!
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.