What Types Of Benefit Claims Are Subject To ERISA?

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Aug 5, 2019

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The Employee Retirement Income Security Act, or ERISA, covers many types of benefit claims such as disability, health and life insurance. However, legal experts say that ERISA’s definition of a “plan” is so broad that it will cover pretty much any type of benefit. So, what claims does ERISA specifically cover?

Guidance from a legal expert

Ron Dean, a California attorney who has been engaged in employee benefits litigation primarily on behalf of participants for over 30 years, is an expert when it comes to ERISA. In a recent interview, he told us that while ERISA can cover almost any type of benefit, some are not. He explained, “[T]he Department of Labor issued a ruling early on excluding unemployment benefits and most vacation benefit plans. While many employers have tried to create ERISA plans for their vacation benefits so they could escape from state laws, most attempts have failed.”

Specific plans

Dean explained the finer points of each type of plan:

  • Disability. Disability Plans generate the most problems. Proving that you can’t work given a particular condition is not a very easy task, especially to an insurance company that hopes to save money by paying fewer claims. Not only do you have to show that you have a serious medical condition, but you have to show that that condition prevents you from working. Most medical conditions are such that some people with them are able to work and others with the same condition cannot. You have to be able to show that you belong in the second category.
  • Health. Health Plan claims present different puzzles. With health care becoming ever more expensive, insurance policies become ever more restrictive – with language even lawyers have trouble understanding. Unfortunately, the courts again have not been very sympathetic to the patient’s point of view and again, usually put the judicial thumb on the insurance company’s side of the scales of justice. Despite the media coverage of a series of sad and sympathetic cases where medical coverage was inappropriately denied, there doesn’t seem to be much change in the immediate future.
  • COBRA. COBRA, the Consolidated Omnibus Budget Reconciliation Act of 1986, benefits present a different set of issues. When, for certain reasons, you lose coverage under your medical plan, you’re entitled to continue that coverage for a period of time but have to pay the premiums yourself. It’s important that you make sure the plan or insurance company gets your payment and your election notice on time. Considering the amounts of money involved, they’re not likely to be forgiving about untimely submissions.
  • Life. Life insurance is also subject to an inappropriate thumb on the scales of justice which makes them more difficult to win. In addition, we see cases involving accidental death, appropriate beneficiary designations and whether death was excluded as “self-inflicted.”
  • Vacation. Vacation benefits require that you get a lawyer involved if the employer is claiming coverage by ERISA. Usually that means the employer is trying to limit your benefits.

Overcoming pitfalls in the claims process

As you can see, the ERISA claims process can be confusing. However, Dean says that timing, review and organization are key components in overcoming the pitfalls employees face when filing an ERISA insurance claim. He provided the following advice:

  • Timing, timing, timing. Be sure to make sure you meet all the time guidelines. People who have these claims are usually already under great stress which makes it even more difficult to work on these claims. Nonetheless, it is critical that it be done.
  • Review and organization. Quickly get the “all the relevant documents” and review them carefully. Review the denial letter carefully (and, if you possibly can, objectively). Gather your evidence, all your evidence. Put it together in a logical order and send it, along with a calm and thorough letter, to the insurance company. Make the insurance company say, “We’ll never get away with denying this one. Let’s move on to someone else.”

If you’ve been denied valid benefits that are subject to ERISA, contact an attorney whose practice focuses in this area of the law. Consultations are free, without obligation and are strictly confidential. To contact a qualified attorney to discuss your situation, please click here.

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