No-Fault West Palm Beach Florida car accident Insurance and ERISA Plan Health Insurance Coverage Letter
[Date]
[Auto Insurance Company]
[ERISA-Governed Health Insurance Company]
Re: [Client/Insured Name]
Dear __________:
Please be advised that I represent __________ regarding injuries he/she suffered in a motor vehicle collision that occurred on __________. Please direct all future communications regarding this matter to my attention.
I understand that __________ has been providing medical coverage for Mr./Mrs. __________ under the terms of a subscriber certificate issued pursuant to an agreement with the __________ plan, which is administered under the protections of the Employee Retirement Income Security Act of 1974 (ERISA). It is also my understanding that the __________ plan and the __________ insurance company paying benefits at the direction of the plan and/or on behalf of plan participants may contain exclusions for coverage of injuries that may also be covered by Michigan no-fault automobile insurance under these circumstances.
I also understand that both the automobile insurance policy governed by the Michigan No-Fault Act and the health insurance coverage described above, may contain competing coordination of benefit clauses. [Enclose a copy of both insurance contracts, if available.]
It is my opinion that if an ERISA-governed health insurance plan and a Michigan no-fault insurance contract have competing coordination of benefit clauses, the Michigan no-fault automobile insurance policy is the primary insurer for all of the products, services, and accommodations reasonably necessary for (Mr./Mrs. has a West Palm Beach Florida car accident claim)__________’s care, recovery, and rehabilitation arising from the __________ motor vehicle collision. Please inform me immediately if either insurance entity identified above intends to take a contrary position.
ON BEHALF OF MY CLIENT, I HEREBY REQUEST A CERTIFIED COPY OF THE MICHIGAN NO-FAULT AUTOMOBILE INSURANCE POLICY ISSUED BY __________ IN EFFECT ON THE DATE OF THE INCIDENT DESCRIBED ABOVE.
I FURTHER HEREBY SPECIFICALLY REQUEST AND DIRECT THE ERISA-GOVERNED HEALTH CARE PLAN DESCRIBED ABOVE TO PROVIDE THE FOLLOWING DOCUMENTS IN ACCORDANCE WITH SECTION 104(b) OF ERISA AND 29 CFR 2560.503-1(h)(2)(iii), I REQUEST COPIES OF THE FOLLOWING DOCUMENTS:
1. A complete copy of the insurance contract/short term and long term disability plan pertinent to (Mr./Mrs. has a West Palm Beach Florida car accident claim)__________.
2. All Summary Plan Descriptions.
3. (Mr./Mrs. has a West Palm Beach Florida car accident claim)__________’s original application for eligibility and benefits.
4. Any and all documents in existence which confer a grant of discretionary authority from the Plan Sponsor to anyone else, Plan Fiduciary(ies) and the Plan Administrator(s), including but not limited to administrative service agreement(s).
5. All documents:
• Relied on in making the benefit determination, including without limitation, all reports, notes, records, test results, correspondence and curriculum vitae of any independent medical examiner/reviewer, functional capacity evaluator, transferrable skills expert, and/or vocational expert;
• Submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination.
Please contact me if you have any questions regarding this matter. I greatly appreciate your assistance and cooperation in resolving any issues pertaining to medical benefits and coverage resulting from the automobile accident described above.
Sincerely,
__________