2 unrelated questions.

1- What is the legal resource when an HMO refuses to pay for a claim that is "clearly" covered under their plan?

I don't know what details woud be relevant to help you help me on this one.

2- I'm applying for a home equity loan and said that I was self-employed (cover for being unemployed) during part of 2005. They want me to sign form 4506, a Request for Copy or Transcript of Tax Form.

What will they be looking for?

(1) very dependent upon the nature of the plan. Is this a plan through an employer? If so, you need to review the plan's summary plan description to determine what the claims and appeals procedure is. You are effectively barred from taking any sort of other action until you exhaust the remedies described therein.

Have you received a formal denial, or have they simply not paid?

(2) Probably verification of your income.

Thank you!

1 is about my mother-in-law, and they have paid half of the claim. Have not "officially" refused to pay, but looks implied.

My concern about #2 is that I've done this before, and have never had to fill out one of these.

I have nothing to hide but am concerned about how deeply they can go into my shit.

(1) may be slightly different then. Regardless of whether a service is covered, HMOs will generally only pay the "usual and customary charge" for a particular service. If the service provider charges more than what is deemed usual and customary (which is, unfortunately, fairly often), then she is liable to make up the difference.

I would file a formal claim (again, pursuant to the terms of the SPD) for the remainder...they are obligated by law to give you a reason for the denial, if they do in fact deny the claim.

(2) just permits disclosure of your tax return. Just be sure to fill out lines 6 and 7 to limit the years they can review.

Thanks! You guys are the best! (and you are giving lawyers everywhere a bad reputation)