Legal Question in Insurance Law in California

I was denied a prior authorization for surgery from my employer health plan citing no coverage due to out of network Tier 4 ambulatory surgery center. Nowhere in my employers summary of benefits or SPD is a tier 4 facility listed or discussed at all. They have tiers 1, 2 and 3 listed. 3 is listed as out of network, for which I am responsible for 30% of the cost. This is what I thought I was responsible for based on the SPD. Is it legal for the health plan to deny my prior auth and surgery for a tier level 4 that is not listed in the benefits summary or SPD anywhere?

Asked on 7/14/22, 1:36 pm

1 Answer from Attorneys

Neither the summary of benefits nor the SPD are legally binding documents. Only the official plan documents are the binding contract of insurance. The summary of benefits and SPD are not required to list every detail of your plan or coverage. Only the official plan documents must be complete. It appears that either your surgery center or your procedure or both are not covered under the official plan at all, and are therefore designated Tier 4. They could also be designated "not covered" and have the same meaning as "Tier 4." Not everything is covered under any given plan. That's why the pre-authorization process exists. If you think there is a mistake and the facility or procedure should be covered as Tier 3 under the actual plan documents, you should appeal the denial, but if it really is not covered, it's not covered whether they call it "Tier 4" or "not covered."

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Answered on 7/15/22, 10:33 am

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