Special Scenarios with Self-Funded Plans

If your health plan is sponsored by an employer, they may “self-fund” their health insurance benefits for employees. This means the employer maintains influence in the final decisions made on payment of medical claims and health care decisions related to plan language. Although the company has contracted with a third party organization to manage and operate the plan, your employer maintains the rights to make decisions as your insurer.

If you are comfortable sharing, keeping your Human Resources department updated throughout your appeal process may give you an ally if your appeal is unsuccessful. Once you exhaust internal and external appeal options, you may consider making a compassionate appeal directly to the top executives within your company for them to make the final decision.