Reg Jones Expert's View

Last week I wrote about the call letter that OPM sends to every plan in the Federal Employees Health Benefits program asking them to submit benefit and cost proposals for the coming year. That got me to thinking about those times when an employee or retiree gets into a rolling-on-the-floor argument with a plan about whether a medical procedure or service should be covered, and, if covered, at what level.

While most plan decisions are correct, there are times when they may not be. When they aren’t, it’s usually because of a difference of opinion about what a contract provision means. The plan says it means one thing and you think it means something else. When differences like that arise, there is an appeals process in place for settling the matter.

However, before you go down that path, it’s important for you to be certain that the ground you are on is solid. Begin by carefully reading the language in your plan’s brochure. The brochure is a contract, and, like any other contract you enter into, you’ll have to rely on the contract language to prove your point. If a medical procedure or service isn’t covered in the brochure or is specifically excluded, you don’t stand a chance of it being covered.

On the other hand, if you’ve done your homework and still don’t agree with your plan’s decision, you should ask them to reconsider it. You can find the procedure for doing that in your FEHB plan brochure. If the plan won’t budge and you still think you’re right, you should write to the Office of Personnel Management (OPM) and ask them to review your claim. Once again, the information you need to do that is in your plan brochure.

OPM will let you know that they’ve received your appeal, and, if they don’t need any more information than you’ve already provided, you’ll usually get a final decision within 60 days. On the other hand, if they need more information, they’ll tell you that within 14 days of the date they receive your appeal. You’ll also be given a phone number in case you want to check on the status of your claim. If OPM sides with you, your claim will be paid. If it doesn’t, you always have the option of filing suit in federal district court.