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A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan

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UNDERSTAND WHAT SERVICES ARE COVERED

Understanding the services that your health plan covers is also important.  You can begin by looking at your health plan contract.  It will contain information about the benefits your plan will pay for, what it will not pay for, and the amounts you will be required to pay when you use health services.

If you are enrolled in an employer-sponsored health plan, you probably received what is called a Summary Plan Description when you first signed up.  Although this document may summarize your coverage in language that’s easy to understand, it is not the legal document that will be used if your dispute with your health plan ends up in court.  For a complete description of your plan’s benefits, contact your employer’s human relations department to see a current copy of what is known as the “Evidence of Coverage” or “Certificate of Insurance.”  If you bought your own health plan, you should have received the Evidence of Coverage when you bought the policy.  If you are not sure if you have a current copy, check with your health plan’s customer service department or your insurance agent.

Health plans limit or exclude payment for many types of services, so make sure you learn about the services your plan does not cover.  Excluded services might include infertility treatments, acupuncture, cosmetic treatments, and treatment of obesity.  Individually purchased plans may exclude coverage for pregnancy benefits, substance abuse, mental health care, or nursing home care.
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Information provided by the Health Care Marketplace Project
Publish Date: 2005-08-04

 

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