You absolutely have the right to sue the insurance company - but only in Federal Court and only after you have exhausted the appeals process and external review, if required - unless you are a special category employee as you described.

Yes .. ERISA places you at a disadvantage in Federal Court ... but if you are diligent in the appeals process and the insurance company fails to respond in a timely manner, you will then have a separate cause of action (breach of contract, failure to disclose under ERISA). You may thus be able to get a cause of action in state court. The specifics of this will vary dependning upon which state you live in and the State Insurance Dept. Regulations. It is always important to request the medical qualifications of reviewers who are involved in the appeals process. It would also help to have your surgeon document the cost of ADR vs alternate procedure (fusion). It will also help if your insurance company has a history of non-compliance or has been fined by the State Attorney General's Office, or has a class action suit against it for deceptive marketing practices. You should request a copy of the contract your employer has with the insurance provider. They are required to provide this, regardless of what they say concerning confidentiality, and I can provide the relevant statutes if requested.
Are there any discrepancies between the materials you were provided when you commenced employment and the current policy? Were you given notice of changes?

Pain and suffering- unfortunately the legal view will be that you could have always financed the operation yourself. This is why you need to look at other causes of action. Does your insurance company have a policy specifically for ADR? If so, is the information in it accurate or does it state any gross factually incorrect information?


My understanding from attorneys is that $70,000 in unreimbursed medical expenses is about the breakeven point at which an attorney will consider it economical to take over a case like this. As most ADR comes in under this, you will probably have to do the legwork and research yourself.