Fighting the Denial of an FEHB Claim

Have you ever been denied the health benefit plan you subscribe to over whether or not it should cover a specific medical operation or service? To our good fortune, we may follow a process to settle disagreements of this kind.

If you disagree with the choice that your plan has made, you have the ability and the obligation to request that they rethink their decision. You may find the instructions for doing so here with each FEHB plan. 

Filing For FEHB Claim

If the plan is not agreeable, you can write to the Office of Personnel Management (OPM) and ask them to evaluate the claim. You should do this if the plan still needs to be more agreeable. Your plan pamphlet also contains instructions on how to carry out those steps.

If you appeal to OPM, you will receive an acknowledgment from them. If they do not require further information beyond what you have already submitted, they will typically communicate their final decision within sixty days. Within fourteen days of the day they receive your appeal, they will let you know if they want further information from you or the plan. This notification will come within the same time frame.

When It Goes Wrong 

They will provide you with a phone number to inquire about the progress of your claim. Consider the matter resolved if the decision goes in your favor. If not, you can bring a lawsuit to the federal district court.

Defending Yourself

Reading the language in the booklet that comes with your plan thoroughly is the most effective strategy to secure an early settlement of a contested claim. Keep in mind that you are entering into a contract with the brochure, just like you would with any other deal. 

You must depend on the contract’s text to defend your argument if there is a disagreement. The next step is to compile all of the evidence that supports your position in the debate. The more effectively you carry out these steps, the higher your chances of success in reconsideration. Finally, if something else is needed, you must argue against everything included in the plan’s reconsideration decision when you go to OPM. 

Remember that it is your responsibility to bring out any weaknesses in the plan’s reasoning and any ambiguities in the contract’s wording. Therefore, it would be best if you benefited from one of these possibilities.

Your chances of having a medical operation or service paid for are practically nonexistent if the brochure clarifies that it needs to be covered or, even worse, expressly excluded from coverage.

Contact Information:
Email: shunsicker@pdfs.education
Phone: 8043014291

Bio:
Stuart Hunsicker is a managing partner, retirement specialist and federal employee benefits specialist here at Purpose Driven Financial Services. As firm co-owner with Zar Razack, the two have a natural chemistry that allows them to work together effortlessly. “Once we decided to really commit to pushing the firm forward, we knew that we could be effective,†Stuart says. “We work very well together and complement each other’s strengths and weaknesses.â€

Stuart considers himself more of the “analytical and numbers†half of the duo. With more than 20 years of experience in the financial services industry, he has become an expert at assessing each individual person’s situation and deducing how much they might need in retirement. Once he arrives at the target number, Zar steps in as a specialist to design a plan that includes specific elements that will help clients reach that number.

A VCU-Richmond graduate with a degree in finance specializing in business, Stuart has seen nearly every side of the financial industry. Early in his career, he worked for smaller firms and was in charge of trading and investment portfolios. He also held a Series 24 license and signed off on variable business within the firm. “I wore a lot of hats,†he says. “I focused on the investment side, but when the markets crashed, I just took too many phone calls with crying voices on the other end.â€

Those tough phone calls led him into the insurance side of the business. He now considers “retirement surety†his focal point and believes in making sure that each client is prepared for retirement before they move to the next step. Once the retirement plan is put into place, the rest is icing on the cake, helping give the client financial freedom.

PDFS certainly isn’t exclusive, but Stuart is extremely passionate about working with teachers and federal workers. His beautiful wife of nearly 20 years, Andrea, is a teacher, so he’s very familiar with the issues they face and tends to gravitate toward clients who serve and assist. He has also experienced many of the hypothetical scenarios he raises to clients. What if a spouse passes away suddenly, or what if you’re forced into retirement early? Stuart has been there, and he knows how to navigate those rocky waters.

He and Andrea have one son, one daughter and eight cats. “We’re the crazy cat house,†he says. His oldest cat is almost 20 years old and was the first to join the Hunsicker family, even before Stuart and Andrea married. The first cat needed a friend, of course, so they adopted one more. Andrea always loved tabby cats, so when her colleague told her that a stray tabby gave birth to a litter of kittens in the backyard, the family loaded into the car to have a look. “When we arrived, there were three kittens. My wife fell in love with the tabby, and my daughter took to a different one, then we couldn’t just leave the third one behind,†Stuart says. “At that point we were known for being the cat people, and it was at that point that three more found their way into our family.â€

Stuart is a massive college basketball fan, even making a trip to the 2022 Final Four. Though he doesn’t have much free time, he and Andrea love to attend sporting events. Stuart also enjoys spending time with family, and they often go shopping, to the beach or to try new local restaurants. He says, “We’re just a normal family that loves being around each other.â€

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Federal Retirement benefits are complex. Not having all of the right answers can cost you thousands of dollars a year in lost retirement income. Don’t risk going it alone. Request your complimentary benefit analysis today. Get more from your benefits.

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