ERISA FAQs 

ERISA FAQs

Employers often choose to provide private insurance benefits, such as disability and long-term care coverage, as a means of attracting valuable employees. Because this coverage is private and policies vary significantly, the federal government implements oversight in the form of ERISA, which guides claim issues. If you have an employment-based private insurance claim that’s been denied, turn to the skilled legal guidance of an experienced ERISA attorney today.  

What Is ERISA?

ERISA is the Employee Retirement Income Security Act, and it oversees how the private insurance that employers are not required to provide but often do – as a work benefit – is handled. The requirements involved break down into the following basic categories:

• Requirements regarding the minimum eligibility of employees
• Requirements regarding policy funding
• Requirements regarding necessary disclosures
• Requirements regarding employee vesting in the coverage

A benefits plan run by your employer usually administers the plan, and the plan delegates the administration of the claims to the insurer.  Both entities are governed by ERISA. 

What Benefits Does ERISA Entitle Me To?

ERISA ensures that the benefits included in the private insurance policies your employer provides you are upheld. The fact is that these policy benefits vary significantly, but if your valid claim is denied, ERISA is a legal mechanism that supports your ability to fight for your rights. 

The kinds of benefits commonly covered by ERISA include:

• Retirement plans
• Medical care 
• Life insurance
• Disability insurance coverage
• Accidental death and dismemberment insurance
• Dental and vision insurance

What Should I Do if My Claim Is Denied?

If your valid benefits claim is denied, you have the right to appeal the denial, and it’s time to consult with a dedicated ERISA attorney.  Under ERISA, you have only six months to gather all your information and appeal a denial. If your appeal is denied, you will not have additional opportunities to provide new information to the insurer.  Under ERISA, if you want to bring a lawsuit after a denial, you must appeal first. And after you appeal, if the appeal is denied, under the rules of ERISA you likely will not be able to put additional information in front of a court if you want to bring suit.  The court is limited to the administrative record, which is all documents the insurer had before when making its decision.

The appeal is thus incredibly important.  You want to gather all evidence supporting your claim, and address any issues raised in the denial letter, including any testing that your insurer said it needed to see to approve your claim.  The appeal culminates in a well-considered appeal letter, which lays out your factual and legal arguments as to why the denial should be overturned. The appeal letter should outline all the important evidence relevant to your claim. Further, it must include compelling reasons why the court should overturn your claim’s denial, as well as a clear request for the benefits to which you’re entitled.  

What if My Appeal Isn’t Successful?

If your appeal isn’t successful, you can pursue the benefits you were denied as well as reasonable attorney fees by filing a federal lawsuit. Depending on your location, the court may review the issue under different standards.  The default standard of review is “arbitrary and capricious,” which means you have to show that your insurer had no reasonable basis for its decision and that the court must show deference to the insurer’s decision.  Many states, including California and Washington, have instituted insurance laws and regulations that result in a “de novo” standard being the norm.  “De novo” means that the court will review the issues based on the facts, and come to its own conclusion about whether benefits should be awarded. It does not need to give deference to the insurer’s decision.

Seek the Legal Guidance of an Experienced ERISA Attorney Today

If your valid benefits claim has been denied, the trusted ERISA attorneys at Monahan Tucker Law appreciate the significance of your situation and are standing by to help. We’re prepared to harness the full force of our impressive experience in pursuit of a case resolution that provides you with the benefits promised to you. Our legal team is uniquely qualified to help, so please don’t wait to reach out and contact us for more information today.