Appealing a denial with a self-funded insurance plan

Large corporations often "self-fund" their health insurance plans. Your employer pays the medical claims and is, in essence, your medical insurer. It hires an outside health insurer to administer the plan.

Self-funded plans are regulated differently than an HMO or a major medical plan run by an insurance company. They are not regulated by the state, which gives members of such plans less leverage. If you've exhausted internal appeals, you'll have to seek the help of the federal government. Specifically, you'll need to contact the Department of Labor's Pension and Welfare Benefits Administration, or PWBA. The PWBA can be reached at (866) 275-7922.

If the PWBA can't help you, your only other legal recourse is to sue your employer. That probably isn't the smartest career move to make.

Another alternative is to get help from the state. While your state's health insurance regulatory body doesn't have any legal authority over your health plan, a patient advocate there may be able to advise and coach you on how to proceed.