Misinformed Customer Reps
Jul 2, 2003
The telephone representatives (of the insurance company) for my employer sponsored health plan have, in the past, given me misinformation about my covered benefits which have caused me financial and other damages. Don't the phone reps have an obligation not to guess when they're not sure about answers? Is the information the telephone reps provide "binding" if acted upon by a trusting plan member?
Response from Ms. Franzoi
The customer service phone reps do have a responsibility to answer questions correctly and if they are not sure to research the issue. However, their representations are not binding. The terms of the plan usually prevail, depending on the degree of the misinformation given, and the plan participant has a responsibility to review written materials provided to him regarding what is covered under the plan. If the written materials are misleading or inaccurate, then your chances for recourse are greater. I would suggest that if the procedure is an expensive one, you should consider filing for a written predetermination of what will be covered. This would provide you with more protection.
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