You are entitled to access to coverage information - a summary of coverage and a summary plan description under ERISA. The DOL website lists out the employer obligations.
i have one for each plan offered. they did not, however, have information related to the specific coverage questions that i needed answered, hence my quest for said answers. i would assume its at that point that the insurance company itself is obligated to answer these things and give direction, and not his employer (or the third party benefits coordinator).
Maybe it's just me, but I found your post fascinating and engaging - not the least bit 'long '. I wanted to set fire to the insurance company at least 5 times before the end.
Your writing, passion and POV is so compelling, I know you have NO time for this, but I would really encourage you to keep writing about your experience. You're an amazing writer. This could be a best seller one day. At least, a fantastic Vanity Fair article.
Keep writing. Keep good notes. You could change the face of insurance with your talent for writing.
I am very sorry. I just spent four hours on Friday dealing with insurance crap and it makes me cry every time I waste one minute dealing with it.
My Doctor's group has a patient advocate that I have used. Most of my appeals are issued by my Dr and I will get the patient advocate involved if needed. Are you able to use a different lab that is covered by in-network? I have a PPO and get blood work done every two weeks. If I used the lab at my specialist's lab, it's not covered but if I use Quest labs, they cover my blood work 100%. Same with the speciality pharmacy.
If you sue, I hope you win! No one deserves this bull shit.
I know it's a PITA but you should take this advice and file a formal complaint with your state's Department of Insurance. The insurance company is required to respond timely to your complaint and the DOI will be the middle man and make sure they do so. Have you filed a formal complaint (not an appeal) with the insurance company? Again, no one should have to deal with this but it may be a route to get your situation looked after.
Although you are not allowed to change plans mid-year unless you have a life-changing event, you feel mislead and did not have enough information to make an informed decision when choosing plans. Your husband's HR may agree and allow you to switch.
I have not yet filed a formal complaint with the insurance company. I am in the middle of writing a letter regarding the incident with the nurse case manager that I dealt with, but I was told the address is a generic po box that I send it to, so I haven't got high hopes for a resolution. I wouldn't even begin to know where to file a complaint about being mislead about an offered plan.
Here's how to start with filing a DOI complaint about being mislead -- Google "your state Department of Insurance file complaint" and you should get to the section on your state's site about filing a consumer complaint. Insurers are required to respond to your letter if you go through your state. You may have to use your state's forms or website.
As for your insurance company, a PO Box is fine, it will get there. Keep copies of your letters and document everything!
I know that you feel like you've exhausted the available help at H's employer, but I think that they need to be assisting you here. While the HR person may not have the answers, she has a client rep that she deals with and she should be escalating this through those channels. I help people with stuff like this all the time. If they don't get satisfaction after their first interaction with customer service, I take it to my account rep. H's employer pays for this plan (at least in part) and they have contracted with the carrier for certain services that need to be delivered. I don't know what the chain of command is there, but I could not tell an employee or their covered dependent that I can't help them with an issue with a plan that we offer.