We Help You Navigate the ERISA Claims Process to Access Vital Employee Benefits
If you work in the private sector, you likely have a package of benefits in addition to your weekly or bi-weekly pay. For example, your employer may provide health care benefits, a 401(k) or pension plan, or long-term disability income if you become disabled. Congress enacted the Employee Retirement Income Security Act of 1974 (“ERISA”) to strengthen the rights of workers who count on these benefits, and to ensure that these plans were subject to the same rules across the country, regardless of the state in which you live or work, Though few employees or their dependents know it, ERISA actually provides them with very strong procedural protections if their benefit claims are denied or calculated incorrectly, they are unable to obtain basic information about their benefits, or many other situations where their promised benefits are at risk of being lost or diminished.
Claiming your benefits.
When you make a claim for benefits and it is denied or incorrectly paid, you may struggle to cover needed medical treatments or ongoing mental health care, or even the basics of life if you are disabled and not working. Or you may believe your retirement benefits were not calculated correctly, impacting your lifestyle in retirement.
ERISA helps in these and other situations by requiring the plan or claims administrator to respond to your claim or questions within certain mandatory time frames. In addition, the response must provide detailed information about why your claim was denied or how your benefit was calculated, so that you may prepare a strong appeal to the plan and have the denial overturned.
Information to which you are entitled. Employer plans are required to provide descriptions of your benefits that are easy to understand, and a written claims process that you may follow to obtain your benefits. Typically this information is contained in a Summary Plan Description, or “SPD.” It is mandatory under ERISA for a plan to provide participants and beneficiaries with an SPD at regular intervals and on written request. If you do not get the information you request, ERISA permits courts to assess penalties against an employer that may be as high as $110 per day starting the 31st day after a written request. Health, retirement, and disability or other plans often do not follow the processes required under ERISA, and it is important to work with an attorney to document these mistakes as you seek your benefits.
Timelines for the initial ERISA claim decision. Once you file a claim for benefits, the plan or claims administrator (usually but not always an insurance company or third party hired by your employer to process claims) must comply with these deadlines:
For a disability claim, the plan administrator has 45 days to make an adverse determination (deny your claim), with up to two 30-day extensions available to them if the administrator requests them properly
For a health care claim, there are different mandatory time periods for urgent care, pre-service, post-service, and concurrent care claims, with the longest decision-making period being 30 days for post-service claims. The other claims have much shorter deadlines
Retirement and other benefits permit the administrator to take up to 90 days to decide.
These are mandatory time frames, and the plan must communicate with you in writing about the status of your claim. The summary above is highly simplified: there are many procedural requirements a plan must follow under ERISA’s regulations, and because of their complexity it is common for plans to make missteps. It is important to work with an attorney knowledgeable about ERISA’s claims procedures as you seek your benefits, so that the plan’s mistakes are documented for any future court action.