The most common customer service questions we address are:
“Is this covered?” and “Why wasn’t this covered?”
Unfortunately, the more frequently asked question is “Why wasn’t this covered?”. A question that comes after an employee has had their insurance claim declined. This usually comes in an Explanation of Benefits note listing what was and wasn’t covered from the most recent submission. Sometimes the reasons are simply due to the general plan rules:
- The claimant has already claimed the annual maximum allowable for a specific benefit or, in some cases, an overall plan maximum
- The benefit (vision, for example) was claimed before its anniversary date.