The Law: Explanation of Benefits
By: Emily Sachar; Source: AARP Bulletin Date Posted: 2007-04-12 17:34:00-04:00
Flora and Thomas Turpin couldn't believe their eyes. Highmark Inc., their insurer, had rejected Flora's bill for an epidural treatment for her back pain. No explanation was offered, Thomas Turpin says.
"It was just so unbelievable. We had the coverage, and they should have paid," says Thomas, 69, of Morgantown, W.Va., a retired coal miner formerly employed by Consol Energy Inc. "Instead, they sent us on a wild goose chase."
That chase—and the class-action suit AARP Foundation Litigation filed on behalf of the Turpins and 2.5 million other Highmark participants—led to a settlement, which the U.S. District Court approved in February. They received a $3,790 payment.
At issue was Highmark's failure on a computerized "explanation of benefits" (EOB) insurance form to adequately explain, as required by federal law, why the Turpins' claims were denied, how to appeal, where to address the appeal and what documents would legitimize the claim.
In January 1998, when a claim filed for Flora Turpin, now 79, was denied, her husband turned to Consol, his former employer, for help—but the firm's human resources office couldn't decipher the EOB form. Four months later, after what Thomas Turpin said was "endless digging," he received a partial explanation: His wife was never notified that she should have enrolled in Medicare Part B, so she missed the sign-up deadline.
Jeffrey Lewis of Oakland, Calif., co-counsel in the case, said Highmark has made extensive changes in its EOB process. Highmark denied any wrongdoing and would not comment further.
Emily Sachar is a journalist and author based in Brooklyn, N.Y.
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