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  1. #1
    Join Date
    Apr 2020
    Posts
    10

    Question Do I Have a Recourse Against Insurance Company Changing Benefits Without Notification

    When I started on Medicare years ago I also signed up for a Medicare Supplement Plan, and received a benefit booklet listing in detail what services are covered and which ore not.
    Recently I was informed by the Plan that a certain procedure was not covered. I called the Plan company and told the representative that the booklet states explicitly that the procedure is covered.
    He asked me what the date on the booklet is and I told him it was January 2004. He then laughed and said that it is totally out of date and experienced several revisions since then, and that the coverage for this procedure has been eliminated.
    I told him that his company never sent me any revised benefit booklet and that my selecting his company and signing up was based on the 2004 benefit booklet. He said he will send me the latest issue if I so desire.
    My question is: Do I have any recourse or is this a lost cause?

  2. #2
    Join Date
    Jul 2018
    Posts
    2,419

    Default Re: Do I Have a Recourse Against Insurance Company Changing Benefits Without Notifica

    Do the plan documents require that the company give notice?

    Are you absolutely sure you never got a notice (even one that says, "hey, your terms of coverage may have changed, and you can check it out at www.yourinsurer'swebsite.com")?

    Did you really think that a coverage booklet from a decade and a half ago would still be valid?

    Do the plan documents say something to the effect that the terms of coverage may change from time to time and that it's the insured's responsibility to ensure that coverage exists before undergoing any procedure?

    Is this a procedure you had performed already? Or is it something you'd like to have performed?

    If it's something you already had done, why didn't you ensure ahead of time that it was covered (or request that your medical provider do so)?

  3. #3
    Join Date
    Mar 2013
    Posts
    18,004

    Default Re: Do I Have a Recourse Against Insurance Company Changing Benefits Without Notifica

    No recourse.
    Lost cause.

    It was up to you to make sure you had the coverage you wanted every year.

    I'll bet that there is something in that old plan booklet that says so.

    Get the current plan booklet and get the update every year.

    Same with Medicare. Medicare publishes the plan booklet every year.

    https://www.medicare.gov/sites/defau...-and-You_0.pdf

  4. #4
    Join Date
    Oct 2014
    Posts
    8,019

    Default Re: Do I Have a Recourse Against Insurance Company Changing Benefits Without Notifica

    Quote Quoting hukre
    View Post
    My question is: Do I have any recourse or is this a lost cause?
    You did not specify in what state you are in and that may make a difference as much of insurance law is state law. That said, the basic way this works is that insurance plans are done on an annual basis with the whatever the rates and coverage options that the insurer offers for the next year. Both coverage and rates change each year, and the public is expected to know that and to inquire with the insurance companies what the plans will cover and what the cost will be rather than simply assuming it's the same every year, though some states do require a specific notice of changes in the premium amounts. Today with many insurers you can just go to their website and see what the policies will cover. Relying on a 16 year-old plan booklet was misplaced. The law on health insurance itself has changed dramatically since then with the passage of Obamacare and other federal and state laws. In light of those changes the coverage offered by insurers changed, too. The plan document for the current year is what determines your coverage, and its your responsibility to check it. Before you have any planned procedure, always check to see if it is covered by your plan and see what pre-authorization is required, if any.

  5. #5
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,433

    Default Re: Do I Have a Recourse Against Insurance Company Changing Benefits Without Notifica

    I would be willing to bet folding money that each year you received at the very least a one-page notice with any change in rates and something on the order of the suggestion made above, "your terms of coverage may have changed, and you can check it out at www.yourinsurer'swebsite.com" if not a description of the actual changes themselves.

    Unfortunately, it has been my overall experience that very few people actually read those notices and often will swear up and down that they never received them.

    Doesn't matter. This is a cause not worth pursuing. Your chances of winning are so low that the instrument capable of measuring them has yet to be invented.

    No, Harold, I am not "trying to scare him". This is actual fact. His odds of winning this one are infinitesimal, no matter what state he is in.

  6. #6
    Join Date
    Apr 2020
    Posts
    10

    Default Re: Do I Have a Recourse Against Insurance Company Changing Benefits Without Notifica

    My thanks to everyone for taking the time and responding to my question; I learned a lot from your comments and I realize that I have to read through all the paperwork which may have been sent together with the annual notice of the payment increase for the coming year.

  7. #7
    Join Date
    Mar 2013
    Posts
    18,004

    Default Re: Do I Have a Recourse Against Insurance Company Changing Benefits Without Notifica

    Same goes for your car insurance and your home or renters insurance.

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