Medical Plan Benefits
Plan administrators have significant discretionary authority in structuring medical benefit plans and in determining what expenses the plans will cover. While plan administrators must not discriminate against participants when reimbursing covered expenses, plans may be written to exclude certain diseases, procedures and medications. The fact that a participant may be part of a protected class of individuals due to a particular disease does not require that plans provide coverage for the disease. For example, a plan may exclude HIV related expenses from its list of covered benefits but the plan administrator must provide covered benefits to HIV patients in a manner similar to other participants. In those instances when covered benefits are denied, there is generally an expedited review process for urgent care needs.

Generally, medical plans make direct payment to providers for their services and participants will not receive plan monies. Accordingly, in those instances when participants require legal representation to pursue unpaid medical expenses such representation often requires a fee retainer. That is because the client will not receive a sum of money from which a contingency fee, i.e. a fee paid as a percentage of the client’s recovery can be deducted.

In many instances, employees may elect to continue their medical plan benefits for a limited period of time when terminating employment. Such continued plan participation is regulated under a section of the Internal Revenue Code known as the Consolidated Budget Omnibus Reconciliation Act or “COBRA”. This act is strictly enforced and an employee’s failure to timely meet all of its procedural and payment requirements can result in the cancellation of COBRA coverage and the non-payment of benefits.

Bruce A. Tischler at firm of Greene & Tischler, P.A. welcomes the opportunity to assist you with your medical benefits.