An Overview Of ERISA And Employer-Provided Benefits
If you are pursuing disability, medical care, life insurance or accidental death benefits provided by your employer, your rights may be protected by a federal law known as ERISA.
The acronym ERISA stands for the Employee Retirement Income Security Act of 1974. Legislators who wrote and passed this law intended for its regulations to ensure fair and consistent administration of employer-provided benefits. Employees typically do not encounter trouble obtaining their rightful benefits, but sometimes a claim is denied.
If you have been denied employer-provided benefits, you may wonder how to assert your rights. An ERISA lawyer can advocate for you in this situation. ERISA may spell out the rules and procedures for your claim. At ERISA Law Center, we can help you cut through the red tape and get access to benefits that you are eligible for.
A Typical Benefit Claims Process
Submitting a claim for ERISA-governed benefits is usually pretty easy. An insurance company or plan administrator may provide you with claim forms. They may have you sign authorizations to allow access to your relevant medical and other records. You may receive requests for more information if necessary.
ERISA requires that plans and plan administrators follow rules and procedures concerning the following:
- Benefit claims
- The denial of benefit claims
- The appeal of denials of benefit claims
Here are some details about common procedures for obtaining disability benefits and other types of benefits covered by ERISA:
- Your employer is usually the “plan administrator” but not the “claim administrator.” The “claim administrator” is usually an insurance company – it actually decides your claim. The plan administrator is required to provide to you, free of charge, a “summary plan description” describing the plan and the plan benefits. You will need a copy of the summary plan description to know your rights. Ask your employer for it if you do not already have it.
- When a claim for benefits is denied, the claim administrator will send you a denial letter, which should explain why the claim was denied and what you need to do to “appeal” that denial, and the time for doing so. The denial letter should also tell you that you have the right to get the records and other documents used to deny your claim. So, if your claim for ERISA-governed benefits is denied, you should ask the claim administrator or insurance company for copies of the documents relied upon to deny your claim. You will need to look at those documents to better understand why your claim was denied. A lot of times, claims for benefits are denied because the claimant (you) did not provide certain types of proof or enough proof of their claim. Many times, this happens because the claimant (you) thinks the insurance company or the claim administrator is getting those records. That sometimes does not happen. But you won’t know that until and unless you get the claim administrator’s or insurance company’s claim file.
- Once you have the summary plan description, the claim file and the letter denying your benefits, you have the basic information you need to appeal the denial of your benefits. But you will need more. The “more” depends on the type of benefit denied. If a disability benefit has been denied, you will need more medical records, any decisions from other agencies that concluded you are disabled and probably some sort of evidence regarding your inability to do jobs the insurance company claims you can do. What kind of other agency decisions? If the Social Security Administration has granted you Social Security Disability Insurance, or a state has granted you state disability insurance, or a state pension plan, such as California’s STRS or PERS, has granted you disability benefits, that is information you should submit in support of any claim you make for ERISA-governed disability benefits.
- If a medical benefit has been denied, usually the doctor who provided the service or proposes to provide the service will prepare an “appeal” explaining why the medical service for you or procedure in question is or was necessary. Make sure the doctor does so.
- Once you get the claim file, you also want to closely read all medical evaluations the insurance company or claim administrator used to deny your benefits. Often those medical evaluations are filled with mistakes and errors. Whether for a disability, medical or life insurance claim, you want to point out those errors.
- In a disability claim, you want to present evidence, such as your statement, that you cannot do the job or jobs the insurance company or claim administrator claims that you can do – and explain why.
- In a life insurance or accidental death and dismemberment claim, frequently, the reason is that the policy has some sort of exclusion, so the benefits are denied if the injured or deceased person was or was not doing certain things.
- Once you have submitted your appeal, that is not the end of the appeals process. First, in a disability or medical benefits claim, the plan or insurance company can require that you attend a medical examination with a doctor of its choice. Second, during the appeal process, if the insurance company or claim administrator develops new or additional evidence to support its denial of your benefits, it has to provide that evidence to you (with certain exceptions) and allow you to comment on that new evidence. Such comments can often be almost as detailed as the appeal itself.
Many appeals are granted, and your benefits are paid or provided. Many appeals are denied, and your only remedy at that point is to file suit.
When Employee Benefits Are Not Covered By ERISA
ERISA applies only to qualified employees, and it does not apply to all employer-provided benefits. Some employers are not subject to ERISA at all. For example, church plans and group benefit plans of government employers are not subject to ERISA. Our attorneys are also available to assist employees whose benefits claims do not fall under ERISA.
Need Assistance With A Claim? Our ERISA Attorneys Can Help.
The process of obtaining employer-provided benefits is supposed to be simple, but it often is not. The claim administrator or insurance company should explain the process and the procedures to you. When they do not, a lawyer can help you assert your rights.
Do you need qualified help to overcome a denial of your ERISA-governed benefit claim or any claim for employer-provided benefits? For answers to your questions or to request a free consultation, call ERISA Law Center at 866-360-0983 or send us an email inquiry.
Via Zoom or phone, our attorneys help people throughout the 9th Circuit – which includes California, Arizona, Washington, Oregon and Nevada – and we’re available 24/7.