What Is ERISA? Why Is It So Important?

The Employee Retirement Income Security Act of 1974, 29 USC § 1001, et. Seq (ERISA) is the federal law governing group benefit plans sponsored by private employers and unions. With a national population of approximately 300,000,000 people, it has been said that ERISA covers approximately one-third of that population.

What Benefits Do ERISA Plans Typically Include?

ERISA covers the following benefit plans:

• Pension
• 401(k)
• Profit-Sharing
• Retirement Plan
• Long-Term Disability
• Health Insurance
• Severance
• Life Insurance
• Prepaid Legal Services

What Are Some Reasons That Professionals Have ERISA Plans?

Professionals have ERISA plans because the pension aspect of these arrangements involves favorable tax treatment. Additionally, welfare benefit arrangements, such as group health insurance and long-term disability, are ERISA plans. These plans can be purchased from a broker, off the shelf, without a great deal of plan design or drafting effort.

When People Reach Out To Your Office, Generally What Stage Are They At In The ERISA Claim Process?

Most people who contact CJ Henry Law Firm do so right after having received a claim denial. Once a claim denial has been issued, the next step is a pre-litigation appeal.

Do Most People Try To Go Through The Appeals Process On Their Own First?

Some people try to go through the appeals process on their own before consulting an attorney, but others do not. However, I do not recommend it since the appeal is often the last chance to get evidence in the record that the court will ultimately see.

How Soon After Filing A Disability Claim Is Someone Notified Of The Decision?

Under the ERISA claims regulations, insurance companies have 45 days to make a decision regarding a filed claim. However, they can take two 30-day extensions, for a maximum of 105 days before deciding.

How Is Someone Made Aware Their Claim Has Been Denied Initially?

Claimants are typically advised in writing, via U.S. mail, that the claim has been denied.

How Often Are Initial ERISA Claims Denied?

ERISA claims are denied frequently. However, the insurance industry likes to note that more than 95 percent of the claims submitted are approved.

What Are Common Reasons For ERISA Claims To Be Denied Upfront?

The most common stated reason for denying ERISA claims is that the claimant has either failed to prove their medical entitlement to disability benefits, or there is an eligibility problem with the claim itself, such as a preexisting condition exclusion. The underlying reason most claims are denied has to do with money. Insurance companies do not like to pay money on an approved claim and will find reasons for denying a claim when possible.

What Facts And Evidence Are The Claims Adjusters Looking At When Deciding To Deny A Long-Term Disability Claim?

When deciding on a long-term disability claim, adjusters tend to look at evidence of the individual’s vocational capacity. Vocational capacity is comprised of several factors, including,

• medical history,
• current medical status,
• pace and tempo of treatment,
• stamina, as well as
• trustworthiness of the claimant.

Does The Insurance Company Have To Give A Detailed Explanation Of Why The Claim Was Denied?

Under ERISA claims regulations, the insurance carrier must provide at least enough of an explanation to allow the claimant to mount a significant appeal of the claim denial.

How Long Do You Have To Appeal An ERISA Claim Denial At The Admin Level?

You have 180 days to appeal the denial of a long-term disability claim.

For more information on Employee Retirement Income Security Act, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (352) 577-7746 today.