The Employee Retirement Income Security Act (ERISA) was enacted in 1974 to protect employees’ pension benefits plans. The experienced ERISA team at Eric Buchanan & Associates wants to help you understand some of ERISA’s terms better and how the law works for you:
1. ERISA Covers Private Employees
You might think that you’re covered under ERISA when you’re not. Only employees in the private sector are covered by ERISA plans. A non-private employer, such as a municipality or other government agency, may offer you a plan, but it will not be considered an ERISA plan.
2. The ERISA Fiduciary
The person(s) or company responsible for managing the ERISA plan is known as the fiduciary. Typically, the employer is technically in charge of an ERISA plan, and has the title of Plan Administrator, and has the responsibility for, among other things, providing copies of all the ERISA plan documents to any employee, plan participant, or plan beneficiary who asks for them in writing. The other fiduciary in many cases is the insurance company that makes the decision on a claim. They are called “claims administrator,” and have different duties from the plan administrator, such as providing all the documents they relied on in making their claim decision, including internal notes, medical records, etc.
3. You Have a Right to Sue the Fiduciary
ERISA allows employees to sue fiduciaries for breach of their duties or for denying benefits. In many cases, complicated rules apply to ERISA cases, that require employees to “exhaust their remedies,” which means that they have to appeal on time to the insurance company and submit everything they want considered. Only after appealing can the employee sue the fiduciaries who made the decision on their case. Taking an insurance company to court may be necessary if you’re disabled and have long-term disability benefits or other ERISA benefits that your ERISA plan refuses to pay.
4. Your State’s Insurance Laws May Not Apply
ERISA trumps state insurance laws in many cases; however, there are certain cases where an employer doesn’t have to incorporate ERISA provisions and may be exempt under state law. Learn the details of the ERISA plan offered at your job and don’t assume coverage. If you don’t understand the ERISA plan documents, ask the plan representative to go over any questions you have.
5. Denials of Claims Occurs, So Appeal
Insurance companies cannot wrongfully deny your claims under ERISA, but they will try. You have the right to appeal any denial of claims, and your best bet to win the appeal is to hire an attorney well-versed and experienced in ERISA law. The most important rules to remember is that, if you are denied benefits under an ERISA plan, the appeal to the plan or insurance company is critical, because if your claim remains denied, a court will only consider the information submitted in support of the appeal, and you cannot introduce new evidence in court; we recommend you hire a good attorney to help with your appeal, because they type of information that needs to be submitted is a very complicated subject. For example, just submitting your medical records or a letter from your doctor is usually not enough to win your case.
ERISA law is complicated and any appeal must be done correctly and in a timely manner. As soon as you receive a notice of denial, seek legal counsel. The professionals at Eric Buchanan & Associates are ready to help.
Getting Legal Help
The experienced disability team at Eric Buchanan & Associates has handled thousands of disability claims, and has many years of experience in disability insurance, ERISA long term disability and Social Security disability law. Give us a call today at 877-634-2506 or email us at firstname.lastname@example.org to set up your appointment.