ERISA is a Legal Minefield—Don’t Go it Alone

, , ,
oklahoma estate planning

oklahoma estate planningERISA is the Employee Retirement Income Security Act of 1974.

If an employer offers insurance as a part of its benefits package (healthcare, dental, vision, disability or any other insurance), they must comply with the policies outlined in ERISA.

When you get hurt and seek ERISA benefits, you must submit a claim to your insurance company. The details (what deadlines you need to meet, the procedure to follow when submittoing a claim) will vary depending on your policy and your insurer’s procedures.

Certain organizations, including churches, small businesses, and government entities, are not required to comply with ERISA. Most other business must follow ERISA standards.

However, there are many problems with ERISA. Instead of allowing claimants an easy path forward toward collecting benefits, it stacks the deck against them in favor of the insurance companies, and it creates many obstacles along the way.

What’s Wrong With ERISA?

Part of the problem with ERISA is the amount of evidence required to deny a claim. A judge can make a decision against the claimant based on very little evidence, sometimes without even meeting the claimant. The judge also gives considerable weight to a “professional” hired by the insurance company to testify, and this person may have failed to fully investigate the details of the case.

Furthermore, there is a disturbing conflict of interest at play in the review process of these claims. Insurance companies employ doctors who review these claims, and they have an incentive to deny claims to help save the insurance company money. Even worse, a lot of these doctors are non-practicing, and only serve the insurance companies in this conflicted capacity. That means if the doctor has a habit of approving claims, the insurance company is likely to find a new doctor.

A Minefield of Potential Errors

Another problem with ERISA is that your initial claim has to be as perfect as possible. You need to build an administrative record and show that you have exhausted every possible avenue of seeking benefits before filing a lawsuit.

The reason you want your initial claim to be as strong as possible is that it’s tough to overturn a denial. If you file an appeal, the insurance provider only needs to submit a small amount of evidence to uphold your denial.

If the judge finds any error or inconsistency in your claim or administrative record, there’s a strong chance that your claim will be unsuccessful. You need to make sure your initial claim and administrative record are iron-clad. A lawyer can help you with this.

Common ERISA Violations

One way to help your claim succeed is to look for any errors committed by your insurance company. Some of these include:

  • Refusing to issue payments
  • Failing to issue payments on time
  • Not valuing their plan at current market value
  • Failing to fully investigate claims
  • Violating the terms of the plan

If you’re having trouble receiving your benefits as mandated under ERISA, contact an attorney to make sure you have the best chance possible of a successful claim.

Written by AskTheLawyers.com™ on behalf of Stephen Nagle.

0 replies
Want to join the discussion?
Feel free to contribute!

Leave a Reply