The 1974 Employee Retirement Income Security Act, commonly known as ERISA, is a federal law that governs all benefits claims from an employee or a group welfare plan.
That includes any type of benefits plan that is established or maintained by an employer, such as health, disability, and life insurance.
Here are five things that you should know about the ERISA insurance process.
1. Know Whether Your Insurance Plan Is Governed by ERISA
If you have insurance like disability insurance or life insurance via your employer, union, or employee group, it is most likely governed by the Employee Retirement Income Security Act.
On the other hand, if you have purchased the insurance yourself, it will typically not be governed by ERISA.
You need to know whether your insurance is or is not governed by ERISA before you can proceed with a claim.
Whatever your situation, it is a good idea to get advice and assistance from an experienced ERISA lawyer.
2. Know Whether You Are Eligible Before You Submit a Claim
Before you can file an ERISA insurance claim, you need to know whether you are eligible.
In some situations, dependents are only insured up to a specific age. Other times, only full-time employees who are actively working are eligible for coverage.
So, before you begin the claims process, check both the Summary Plan Description and the Summary of Benefits and Coverage in your insurance policy to discover whether you qualify to receive benefits.
3. Know Where to Send Your Claim
Once you know you are eligible and have completed the claims forms, you need to ensure your claim is sent to the right destination. You also need to make sure that you have attached any additional documents that are required.
You will find the information on where to send the forms and which documents to include in the Summary Plan Description of your policy.
You may need to first contact your employer to request claim forms and gain the relevant details needed for completing the forms. Alternatively, a lawyer can do such things on your behalf.
4. Do Not Miss the Deadline
Insurance claims have deadlines. It is vital that you do not miss the deadline for your claim if you want it to be approved.
It helps to keep thorough records of the communications with your insurance company and your employer.
5. Know What to Do if Your ERISA Claim Is Denied
If your insurer denies your ERISA claim, the company must send you a letter of denial in writing.
It needs to include information like the reasons for the denial, the specific provisions on which the denial was based, and which documents were reviewed during the claims process.
The letter will also inform you of how to appeal and what additional information you need to provide as part of your appeal.
You will be given an appeal deadline too, so make sure you do not miss it.
Typically, you need to submit an administrative appeal before you are able to take further action and file a lawsuit against the insurer or employer.
So, make sure you go through the proper channels in the right order to maximize your chances of recovering the fair benefits you are owed.
If your ERISA insurance claim is denied and you decide to appeal, it is a good idea to hire a lawyer, as you will stand a better chance of winning the appeal and gaining the benefits you are entitled to.