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What Is An ERISA Insurance Claim?

Fri Nov 3rd, 2017 on     Disability Insurance,    

If you are covered by an employee benefit plan (life insurance, pension, health, retirement benefits, etc.), and you work for a private industry employer, then in all likelihood, your plan is governed by ERISA regulation.  ERISA can have important ramifications for your insurance claims and the process by which you can seek proper recourse in the event that your claims are wrongfully denied.

What is ERISA?

The Employee Retirement Income Security Act (ERISA) was enacted into federal law in 1974 to establish standards for private employee benefit plans.  ERISA does not mandate that employers sponsor private benefit plans for their employees, but it ensures that when employers do offer benefit plans, they abide by various regulations relating to accountability, reporting, fiduciary duty, conduct, disclosures, and more.

Thanks to application of the interstate commerce doctrine, federal ERISA regulation applies to employee benefit plans whether or not the employer’s business crosses state lines.  For example, a small three-person firm in Miami will be governed by ERISA (with regard to benefit plans offered by the employer), even if the firm only works with Florida-based clientele.

Your benefit plans will not be governed by ERISA regulation if you are a public employee or the employee of a qualified religious organization.  ERISA applies only to benefit plans offered by private employers.

Consequences of ERISA for Claim Denial

As an insurance claimant, ERISA affects the basis and process by which you obtain benefits when your claim has been denied.

If your insurance provider denies your benefits claim, then they must — pursuant to ERISA regulation — provide you with a written notice fully explaining the reasons for the denial of your claim and outlining the process for appealing their claim denial.  You will then have six months to file an appeal with the insurer.  ERISA regulation requires that the insurer provide you with any record evidence that is reasonably material to your benefits claim, and must notify you as to the identify of any industry experts they relied on when they decided to deny your claim.  The appeal is then reviewed within a reasonable timeframe (ERISA sets different time limits depending on the nature of your benefits claim).  By working with an experienced insurance attorney, you can make sure that delays are minimized.

You may choose to file suit against the insurer because the claim was wrongfully denied.  It’s important to note, however, that despite you being in Florida, your lawsuit will be governed by federal law and will be litigated in a federal court.

If your benefit plan is covered by ERISA and you have had your claim wrongfully denied, you may be entitled to appeal the denial, and — failing to secure a favorable result during the claim appeal process — you may thereafter be entitled to bring a lawsuit against the insurer on the basis of such denial.  Insurance litigation can be complicated, however, and an expert understanding of ERISA regulation, as well as the particular facts of your insurance claim and the circumstances surrounding the denial of benefits will be critical to obtaining the recovery you deserve.

Call 305-577-3996 to speak with one of the experienced Miami disability insurance lawyers here at Ver Ploeg & Marino today.

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