Enough to be Dangerous

By: Ron Peck, Esq.

In my time, I’ve encountered opposition that admits to knowing nothing about the topic, and seeks to engage me in common sense discussion; and, opposition that blows me away with the level of in-depth knowledge they possess as it relates to the topic being discussed.  Then, there are those who know just enough to be dangerous.  One issue I’ve been running into relates to attorneys that “know” benefit plans are required by law to provide a notification of adverse benefit determination any time they pay less than the charged amount.  They accuse the plan, however, of failing to meet this obligation – as they only provided an EOB, which utterly falls short of a voluminous list of requirements bullet pointed by ERISA.  They demand this list, even when the reduced payment arises from a network discount!  What do you think?  Is an EOB adequate in most cases, to meet your legal duty to provide written notification of adverse benefit determination, when payment is less than the charges?  In my time, I’ve discovered that most of those “demanded” details are actually only required from the plan in very specific circumstances; though – I agree that EOBs ought to feature more specificity and direct participants to the applicable provisions in their plan documents.  If you’d like to discuss how to do that, give me a call.