Self-Funded Employers & ERISA Law

ERISA is ..well, I don't know what to call it. It's, as best as I can describe, a federal law that governs companies who self fund their benefits programs...like my employer.

Well, as you have read in my previous post, Highmark BC/BS has denied me 2 times. Because I live in MASS I have Highmark but if I work for my company and lived in CT (1/4 mile down my road) I would have Cigna. Our companies Cigna plan covers this procedure. It's in black and white in the policy guidelines and coverage position.

Within the ERISA's wording are guidelines that all self-funded companies have to obide by. One is that "similarly situated" employees must be offered uniform benefit and no discrimination is allowed.

I think this may be where the light is peeking through the clouds. I pay EXACTLY the same amount each month as my co-worker who lives in CT. However, she has Cigna and can get the operation and I don't. Doesn't seem very fair does it.

Well, Highmark is sending me the appeal paperwork to send in to my employer (2nd appeal) and I am going to mention ERISA and see what happens. I'm not sure if I'm interpreting it correctly but I don't think I'm too far off the mark.

We'll just have to see what happens. Is anyone out there fighting a denied claim against a self-funded employer? Just wanted to know what everything thinks about my theory.

Thanks,

Gina B.

PS....I got the ERISA info from the Gov't website and was directed to it by an article I saw about Harrahs finally covering Lap Banding