Q: What limitations, exclusions and reductions are included in Brella’s certificate of insurance and riders?
A: While Brella is much simpler than most supplemental plans on the market, our plans have some limitations, exclusions, and reductions of coverage that apply in certain situations. A complete description of benefits, limitations, and exclusions are provided in the certificate of insurance and riders, but we’ve included a summary below.
Your Brella plan pays benefits if you are diagnosed with any of 13,000+ covered conditions during the plan year. You can file a claim any time you are diagnosed but there are a few limitations you should know about.
First, our plans have separation periods, which means that after you file a claim, you can’t file another claim in the same category (Moderate, Severe, or Catastrophic) until the separation period has passed between the dates of your diagnoses. The separation period for Moderate claims is 14 days. For Severe claims, the separation period is 30 days, and for Catastrophic claims, the separation period is 90 days. The separation period only applies to claims in the same category, so if you are diagnosed with a covered Moderate condition and a covered Severe condition at the same time, you can file claims for both.
Other Claims Limitations
If you’re still in ongoing treatment after the 90 day Catastrophic separation period ends, you may be able to file another claim under certain circumstances. However, you can only file a maximum of 3 times for an ongoing condition within the same condition group in your lifetime. However, if you have multiple catastrophic conditions during the year (for example if you have a heart attack in January, cancer diagnosis in April, and Alzheimers diagnosis in August), you’ll be covered since they are in different condition groups and the 90 day separation period had passed between diagnoses.
You can enroll in Brella anytime throughout the year but if you enroll, or add a family member, after the Open Enrollment period has ended, you are considered a “late entrant” and you will have a 60 day waiting period before any claims will be approved.
We will not pay benefits for an Injury or Sickness that is contributed to, caused by, or resulting from:
Reductions of coverage
Benefits may be reduced at ages beyond standard retirement age. At age 70, your benefits reduce by 50%. Coverage ends at age 80.
Renewability, Cancellation, & Termination
Our plans are group policies, and are annually renewable. Your continued coverage depends on whether your employer renews the group policy. If your employer does not renew the policy, coverage ends for all employees. If your employer renews the policy, you will have the option to continue your coverage. Premiums may change on the policy anniversary and your employer’s contribution to policy premiums may also change. You may choose to terminate coverage before the next policy anniversary by letting your employer know your choice in writing.
Q: How can I appeal a claims decision?
A: You can request a review of a benefit determination by submitting your appeal to us in writing at the following address:
Brella Services Appeals
2093 Philadelphia Pike #2496
Claymont, DE 19703
The request for review must be made within 180 days from the date you receive notice of our benefit determination. If you request a review of a claim denial, we will complete our review no later than 30 days after we receive your request for review.
If your plan is governed by ERISA, you may have the right to file a civil action under ERISA if all required reviews of your claim have been completed.
You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents, or other relevant information to the appeal address referenced above. You may request copies (free of charge) of information relevant to your claim by contacting us at the above address.
Availability of Consumer Assistance/Ombudsman Services:
There may be other resources available to help you understand the appeals process. If your plan is governed by ERISA, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272). If your plan is not governed by ERISA, you can contact the Department of Health and Human Services Health Insurance Assistance Team at 1-888-393-2789. Your state consumer assistance program may also be able to assist you at: Texas Department of Insurance, Consumer Protection Services, 1-800-252-3439.