Reg Jones Expert's View

There are few things more frustrating than getting into an argument with your health benefit plan over whether a medical procedure or service should be covered. While plan decisions are usually correct, they aren’t always. Where disputes are most likely to arise is in the interpretation of a contract provision. The plan says it means one thing, you say it means another. Fortunately, there is a procedure for resolving such disputes.

If you don’t agree with your plan’s decision, you can ask them to reconsider it. The procedure for doing that is printed in each FEHB plan brochure. If the plan doesn’t agree with you and you still think that you are right, you can write to the Office of Personnel Management and ask them to review the claim. That information is also in the plan brochure.

Once OPM receives your appeal, they will send you an acknowledgement. If they need no further information, they’ll get a decision to you, usually within 60 days. If they need more information from you or the plan, they’ll let you know that within 14 days of the date they receive your request. They’ll even provide a phone number so you can check on the status of your claim. If the decision is in your favor, great. If it isn’t, you are free to file suit in federal district court.

The best way to get early resolution of a disputed claim is for you to carefully read the language in your plan’s brochure. Remember that the brochure is a contract, and it’s like any other contract you enter into. When there is a dispute, you must rely on the contract language to prove your point. Then marshal all the other facts supporting your side of the argument. The better you do this, the more likely you are to win in the reconsideration phase. If that doesn’t work, you will only need to brush up your arguments to counter anything that came in the plan’s reconsideration decision when you go to OPM. A well argued case could reveal flaws in the plan’s arguments or point up any lack of clarity in the contract wording. Either of these should work in your favor.

Still, it’s worth remembering this: If a medical procedure or service isn’t covered in the brochure or, worse still, specifically excluded, your hope of getting it covered is close to zero. Nevertheless, your arguments about why it should be covered may lead to its being included in the following year’s contract. OPM contracting officers have a keen eye for what should be, not just what is.