Filing stop loss claims is not part of most people’s daily routine, thus it is easy to miss important deadlines. But waiting to file stop loss claims increases the risk of missing the claims filing limitation under the policyholder’s stop loss contract.
The prompt filing of claims benefits all parties:
- Policyholders obtain the reimbursement quickly and are able to better manage budget fluctuations and investments.
- Agents and TPAs add value by helping the policyholder avoid missed deadlines.
- Stop loss carriers are able to partner with the claims administrator to make sure that the best managed care claim discounts are obtained.
Review Your Policy
The claim submission deadline is important for prompt and timely claim reimbursements.
If you haven’t recently taken the time to review the claim filing provisions of your stop loss policy, here are some of the pertinent contract provisions as they appear in Symetra Life Insurance Company’s stop loss policy:
The Participating Employer will give written notice of Individual Excess Loss claims to Symetra within 31 days of the date the Covered Expenses, with respect to a Covered Unit or Covered Family Unit, have reached the Individual Deductible.
In other words, the claim should be submitted to Symetra within 31 days after the date the individual deductible is met.
Late Claims
What happens if the claim is not submitted within the 31 days? The contract states:
The Participating Employer’s failure to furnish written notice within 31 days will not invalidate or reduce any claim if it were not reasonably possible to provide written notice within such time.
We realize you are busy. If the claim isn’t filed within 31 days after the date the individual deductible is met, it is not too late to submit the claim. In fact, the participating employer has up to one year after the individual deductible is met to provide written notice of the claim to Symetra. The contract states:
. . . written notice must be furnished as soon as possible, but in no event later than 1 year after the date the written notice is first required.
In other words, written notice of a claim should be submitted to Symetra anytime between 31 days and one year after the date the individual deductible is met to avoid denial of the reimbursement request for untimely filing.
Best Practice
The best practice is to submit the claim as soon as possible after the individual deductible is met so that our mutual customer receives its reimbursement as soon as possible. Nobody benefits from the delayed filing of claims. Making time to run stop loss claim reports monthly will help expedite reimbursements.
If you have questions about Symetra’s stop loss policy or an individual claim, visit our web site or contact your Regional Claims Office  .
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