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Frequently Asked Questions Insurance

My friend received bad information from a Plan's customer service representative and received care based on that bad information. My friend thinks the Office of Personnel Management should order the plan to pay or allow a mid-year plan change. I don't think it should do either. Who is right?

You are correct. Problems arising from oral discussions are very difficult to settle later because they are impossible to prove or disprove. In contractual situations such as under the Federal Employees Health Benefits Program, oral statements can never be regarded as official and, so, the brochures state that oral statements made by any representative of a carrier cannot modify the benefits described in the brochure. If a serious decision -- such as whether to enroll or not enroll in a plan -- hinges on such a coverage issue, do not rely on a verbal response. This is particularly true if the response disagrees with the plan's brochure benefits description.

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