If a carrier affirms its denial, you have a right to a review by the Office of Personnel Management. Image: vinnstock/Shutterstock.com
By: FEDweek StaffThe FEHB program has provisions for challenging the denial of a claim for coverage if you think that claim was wrongly denied.
A carrier must reconsider its denial on receipt of a written request within six months after the date of the denial. This time limit may be extended if you show you were prevented by circumstances beyond your control from making your request within the time limit.
In your written request state why you believe your carrier should pay the claim or provide the service. Your reasons must be based on the specific provisions in your plan’s brochure.
Within 30 days after receipt of your request for reconsideration, the carrier must: affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If this information is not supplied within 60 days, the carrier will base its decision on the information it has on hand.
If the carrier affirms its denial, you have a right to a review by the Office of Personnel Management to determine whether the carrier has acted in accordance with its contract. You must request OPM review within 90 days after the date of the carrier’s letter affirming its decision to deny your claim. OPM will not review your claim unless you demonstrate that you gave the carrier the opportunity to reconsider its initial denial.
Along with your request for review, you must send: a copy of your letter to the carrier requesting reconsideration; a copy of the carrier’s reconsideration decision; copies of documents that support your claim (such as operation reports, bills, medical records, explanation of benefit forms); and your daytime telephone number.
You may ask OPM for a review if the carrier fails to respond within 30 days after your written request for reconsideration or 30 days after you have supplied additional information.
To request review write to: Office of Personnel Management Retirement and Insurance Service Office of Insurance Programs P.O. Box 436, Washington, DC 20044-0436.
You may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies, or drugs covered by your plan until you have exhausted OPM’s procedure. If you decide to seek judicial review of the denial of a claim, you must file suit no later than December 31 of the third year after the year in which the care or service was provided. Damages recoverable under federal law are limited to the amount of benefits in dispute. Such legal actions must be brought against OPM.
Federal Pay Raise in 2026 Unlikely; Trump Expected to Affirm Decision by End of Month
DoD Announces Civilian Volunteer Detail in Support of Immigration Enforcement
Urban Policing Order Calls for Hiring Federal LEOs, Deputized Guard Unit
Ruling on CFPB Job Cuts Could Affect Challenges to Other RIFs and Reorgs
Schnitzer: How to Challenge a Federal Reduction in Force (RIF) in 2025
See also
Attorney Schnitzer: How to Challenge a Federal Reduction in Force (RIF) in 2025
Alternative Federal Retirement Options; With Chart
Primer: Early out, buyout, reduction in force (RIF)
Retention Standing, ‘Bump and Retreat’ and More: Report Outlines RIF Process
