ERISAconsultant.com

Is My Claim Covered by ERISA? 

Q:  I've been told that some insurance claims are covered by ERISA, and others aren't.  Is that true?

A:  Yes.  Insurance claims made under employee benefit plans in the private sector are generally covered by ERISA.  Benefits for government employees and employees of religious institutions are not covered.  Claims made under personally-purchased insurance policies, like homeowner's and auto insurance, are not covered.

Q:  My private-sector employer provides benefits that are self-insured; there is no insurance coverage involved.  Do these benefits come under ERISA?

A:  Most likely.  Insurance coverage is not a requirement for ERISA to be applicable.  For example, employer-sponsored retirement plans and profit-sharing plans are covered by ERISA.  What's important to know is whether it is an employer-sponsored employee benefit plan; if it is, it's probably an ERISA plan.

Q:  Vacation and sick leave are employee benefits.  Are they ERISA plans?

A:  No.  Employee leave benefits don't really require a lot of administration, and so they are not considered a "plan".  Since there is no "plan", ERISA does not apply (nobody said this was easy).

Q: How can I find out if ERISA applies to my claim?

A:  Ask your employer.  Your head of Human Resources should know.  If your employer can't tell you, that's a sign of trouble, and you should talk to an ERISA lawyer.

My Claim was Denied -- Now What?

Q:  My claim was denied by the insurer. They say I can "appeal" the decision.  Should I?

A:  Yes.  The denial letter should have told you the reason for the denial -- read it carefully.  It also should tell you how soon you must appeal, as well as the address of the person to whom the appeal should go. 

Q:  What should be in my appeal?

A:  This is very important: everything that can possibly help you to overturn the denial of benefits must be included now.  If you don't include these things now, it's very unlikely you will have a chance to include them later.  These may include doctors' reports, x-rays, nurse's notes, affidavits of witnesses, reports of rehabilitative and occupational experts, and citations to relevant law.

Q:  But the denial letter from the insurance company doesn't say I need to do all that.  Don't most people just write a letter that says "I appeal" and send it back?

A:  And that's why most people lose their appeals and fail to make an administrative record that will convince a judge to order the insurer to pay the claim.

Q:  Don't I get a trial with a judge if the insurer denies my appeal? Can't I put in my helpful evidence then?

A:  Most ERISA cases don't have trials.  Instead, the judge reviews the documents created by the insurer to deny the claim, as well as the documents the employee submitted to the insurer.  All of this is called the "adminstrative record."  The lawyers then make arguments to the judge about whether the administrative record supports the insurer's decision or not.  It's unlikely you or anyone else will testify before a judge or be able to submit new evidence.

Q:  If the administrative appeal is that important, do I need a lawyer to prepare it?

A:  It is usually very helpful.  Most ERISA lawyers know to promptly request certain documents from the insurer or the employer, so an appeal can be prepared effectively.  They should also be able to locate medical and other experts who can prepare relevant reports before the appeals deadline.  They can also spot errors in the insurer's denial paperwork.

Q:  Wasn't ERISA designed to eliminate the need for lawyers and make the claims process "non-adversarial"?

A:  Perhaps that was the intention, but many people claim that some insurers take unfair advantage of the system by routinely denying even clearly meritorious claims. 

My Employer Won't Give me Information About my Retirement/Health Care/Disability Plan.  How do I Get This Information?

Q: My employer won't respond to my questions about benefits.  What do I do?

A:  The first thing to do is deliver a letter to the employer clearly asking for all information about your ERISA plan, and keep a copy.  Ask for the "summary plan description" for each plan, a copy of the most recent "summary annual report" and, for retirement plans, a statement of your current balance of retirement benefits.

Q:  What if the letter is ignored?

A:  A federal judge can order a penalty of up to $110 per day for each day the information is delayed beyond 30 days from your written request.  The employer pays that penalty to you.

Q:  What else can I do?

A:  Contact the Department of Labor in Washington, D.C.  They may be able to help.

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.