Question
What is the name of your state? FL
Here's the deal...Two days after I had a baby, my husband filled out and turned in the paperwork to his employer to add our newborn onto our insurance plan. After a two month check-up we received a denied claim in the mail stating our newborn was not included on our policy. We went down to HR dept. and they said they had no record on file that we had turned anything in, so they said we needed to explain everything in an appeal letter. Did that, and I just received the decision letter that it is STILL denied. Letter stated we had 60 days to add the newborn and they never received paperwork from the employer...and we have to wait until next open enrollment of 2006. I don't know if they even read our "explanation" but we DID turn in paperwork and it was appearently lost somewhere in the HR dept. What am I supposed to do now? Seems this secretarial mistake is going to cost me several thousand as I already owe for the first round of immunization shots. What are appeals even for?!
The bottom of the letter said I could re-appeal...is that the only option? And what if they just deny it again? It took 2 months just to get the first appeal response. HELP!
Answer
1st, make arrangements to pay the outstanding bills. Your credit will suffer if you don't, even if you straighten out the coverage issue later on. If you can't pay it all at once, call the health providers and set up a payment plan if one is available.
2nd, follow your internal grievance procedures with your employer. You've reported this to HR, now follow your company's next step in the grievance process.
IMO, there is not much value with continuing to pursue this with your insurance company directly. This seems to be an issue only your company can straighten out now.
Answer
Thanks I have already accepted the fact that I am paying for all this.
Spoke with someone again in HR today. Pretty much said even if the paperwork was lost on their end ultimatly it was our responsibility.
Problem is....newborn was covered for the first 31 days by US law. So it appeared that she was covered under our insurance as all of the first claims were "covered"
I guess I lost this battle. Word to the wise. Quadruple check someone elses work.
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I think that the battle here isn't between you and the insurance company, it's between you and the employer. HR stating that even if they lost the paperwork it's still your problem is ridiculous (and I'm in HR!) I suggest you escallate this issue over HR. Who does the head of HR report to? That's the person you need to contact. You ought to escallate this all the way to the CEO if you need to. This CAN be fixed and handled very simply as an "administrative error" and late enrollment paperwork sent into the insurance carrier.
Answer
Well, this HR is sort of a middleman between us and the state. Ultimately it is what the State decides. Our HR did write a letter explaining that paperwork was lost on their end. It was the people OVER HR who said no. I am filing another appeal, but this time my letter will be so detailed with info it will make their heads spin. Dates, times, peoples names, explanations, reasons etc. I think my first letter was a bit too general stating our problem here. If they deny it again can you imagine what kind of pain in the neck I will be at open enrollment???!! I'll call every day asking where enroute the paperwork lies. Is it on the desk? Is it in the mail? Is it in the data entry dept? Is it in the trash like the last paperwork I filed? WHERE IS IT?! Ha ha
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I guess I'm confused. Is your employer a state agency? If not, how does the state fit into this?
Answer
No. My husband is a "state employee". (ex. gov. offices, public schools etc.) So, there is an HR where he works, but they forward everything to the state. I guess you could say the state has a big HR office, but they would not be able to handle the millions of state employees so each location has an HR dept like any company would.
My goal is to relay this on to them: It appears that if I turn in paperwork and don't follow up it is my fault here. So let's say I followed up 3X and in the end it still got lost. Still my fault? What if I followed up 10X and for some freak reason it still got lost...my fault? Point is, so what if I did not follow up. I turned it in to the right people so those people need to fix it.
Did I mention this message board has been very therapeutic?