Expert's View

If you’ve ever had a problem getting a disputed health benefits claim resolved, you’ve probably wondered what’s the best way to handle it. Before I tell you, let me put in a plug for the system. By and large it works well. Cases get handled accurately and in a timely manner. However, depending on workload and staff availability, even an efficient system can grind to a halt, and, on rare occasions, a case gets lost. If that happens to you, what do you do?

Well, if you have already been in touch with a case worker and gotten a plausible reason why your case has been delayed or, better still, a date on which to expect an answer, I suggest that you be patient. But, if nothing happens, even with repeated calls or letters, it’s time to escalate the matter above the worker bee level.

Stage one is to write to the head of the organization explaining the problem and asking for a speedy resolution. For health insurance matters that would be Robert F. Danbeck, Associate Director, Division for Human Resources Products and Services, OPM, 1900 E Street, NW, Washington, DC 20415. Your letter will cause pressure to be put on the staff handling your claim. If you don’t get a speedy resolution, go to stage two. Write the head of OPM, Linda Springer, at the address above. Agency heads expect an even faster response from staff than does the organization’s top manager. It’s extremely rare that any matter needs to be pursued beyond this level.

Of course, you can write to your Member of Congress and ask him or her to intercede for you. However, from long experience running the program, I can tell you that this rarely gets faster results than staying within OPM’s own system. In general, congressional inquiries only create an additional layer of paperwork that needs to be cleared away when providing you with an answer.

That’s not to say that there aren’t times when writing a Member could be productive. In this category I’d put matters of law or regulation that you believe ought to be changed, for example, increases or adjustments to health benefits coverage.