The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that governs most employer-established pension and health plans in the private industry.  If your employer funds your health plan or long-term disability plan and you pay into it, the plan is likely governed by ERISA (so long as your employer is not a church or government entity).  While ERISA is often seen as one-sided because it is tilted in favor of the employers to provide an incentive for them to establish ERISA plans in the first place, it also provides protections to employees and their family members when an ERISA plan denies their claims for benefits.  Incidentally, ERISA may provide similar protections and procedures to healthcare providers that rendered services to employees and their family members covered by an ERISA plan.

Consumer Claims
Employees, as well as their family (beneficiaries) can not only request certain documents to help understand a denial, but they can also appeal their denial.  Typically, these appeals start at the administrative level.  That is, the ERISA plan or its administrator takes a second look at the employee's claim.  The employee often has the ability to present additional evidence at this stage.  That is important!  That is the time to hire an attorney to help you figure out what the ERISA plan wants from you and your doctors.  That is the time to hire an attorney to help you present your best case to the ERISA plan.  The employee can then appeal in federal court.  But the huge difference is the Court is typically limited to reviewing the evidence that was presented to the ERISA plan or its administrator.  The Court will typically not hear any new evidence at this stage.  Thus, if you are having an issue obtaining benefits from an ERISA Plan, let us see if we can help.

Provider Claims
Similarly, healthcare providers may have to deal with ERISA plans because they provide treatment to employees and their family members (beneficiaries) who have healthcare through an ERISA plan, but the ERISA plan denies the provider's claim for benefits.  Even though ERISA plan administrators are supposed to owe a fiduciary duty to the employees and their families - act in their best interest - some ERISA plans act more like insurance companies and find creative ways to deny claims for benefits.  Moreover, unlike insurance companies, ERISA plans may not have contracts with healthcare providers that determine the reimbursement rate for the providers' services ahead of time, which leads to problems when healthcare providers submit claims for benefits relating to the services they rendered.  This puts healthcare providers in the difficult position of having to consider suing their patients to obtain payment, which few healthcare providers like doing.  Yet, healthcare providers may have the option of administratively appealing the denial of benefits to the ERISA plan, and even appealing to a federal court.  If you are having an issue obtaining benefits from an ERISA Plan, let us see if we can help.