If you are an employee or family member of an employee who receives health benefits from a health plan provided through employment in the private sector, a federal law, the Employee Retirement Income Security Act (ERISA), protects you. Among the protections, ERISA sets standards for administering these plans. Those standards require plans to give you important information about the plan and to have a fair process for handling benefit claims.

 

ERISAClaim.com Notes:   If you have health insurance (benefits) from your job in private-sector, you're covered under ERISA, Employee Retirement Income Security Act of 1974, the federal law. "Protects You": ERISA regulates and governs your insurance dispute and denial, this is true for both self-insured and fully-insured health plans (your employer bought a group insurance policy). ERISA, the federal law, requires insurance company and HMO to tell you everything (Information) and ERISA guarantees your rights and fair processing of your claims and appeal of denials. ERISA, the federal law, instead of state insurance laws, regulates your health insurance dispute and denials if you're covered from private employer sponsored health plans.

The first step you should take - even before you are ready to file a benefit claim - is to carefully read your plan's summary plan description. This is a document which your plan administrator must furnish to you after you join the plan. You can also request a copy from your plan administrator. The SPD gives you a detailed summary of your plan - - how it works, what benefits it provides, and how they may be obtained (the process for filing your claim). The summary plan description is also required to describe your rights and protections under ERISA.

 

ERISAClaim.com Notes:   Under ERISA, the insurance policy is called SPD, Summary Plan Description, ERISA version of insurance policy. Your employer or anyone in charge of the health insurance must give you a copy of SPD as required by federal law. SPD has everything about "what is covered" or  "what is not covered", including pre-existing condition, deductible, PPO, HMO, and who is legally responsible for your claim processing and dispute. Many SPD's are publicly available on Union or Company intranet or website: 1199SEIU National Benefit & Pension Funds - SPDs; US AIRWAYS SPD. If you requested for a copy of SPD and didn't receive it as specifically required by ERISA, the entity or individual responsible for this compliance will be fined for up to $110 per day by federal court.

 

All plans have rules governing what benefits they offer and how to apply for them. For example, some plans may require you to file a claim (seek authorization) before you can receive medical treatment. Some plans may have special rules for urgent care. For other plans, you must submit a claim for reimbursement after receiving and paying for the care yourself.

 

ERISAClaim.com Notes:   ERISA has rules for your health insurance and for you, it is outlined in a document, ERISA version of insurance policy, SPD. Insurance companies must follow these rules and procedures. You must also specifically follow these rules to get your claims paid, and to follow the steps outlined in SPD if your claims are denied. If you can't follow these rules, you won't get your health care or won't get claims paid from your insurance.

 

Your plan's claims procedure should state the time within which the plan must provide you with a decision on your claim. Be sure to look for these in your SPD. When you submit a claim to your plan, note the date and keep track of the time as you wait for a decision. Some plans may have different time periods depending on the nature of the benefit claim - such as if the claim is for urgent care or whether the claim is filed before medical care is received or after. Some plans' procedures allow the plan to extend the time period. Your plan's claims procedure should provide for the plan's notification to you of the plan's decision on your claim for benefits. If you do not get a response from your plan within the specified time period, contact your plan administrator.

 

 

ERISAClaim.com Notes:   ERISA has very specific rules on timelines your insurance HMO/PPO must follow after you send your claims. Different types of claims require different timeline for response. ERISA "Promt Pay" timeline can be found by clicking here and check below.

 

Your plan may deny a claim for many reasons. For example, you may not have met the plan's annual deductible, the requested treatment may be something the plan says is not covered or not medically necessary, or you may not have filed enough information for the plan administrator to process the claim. Look for the reason and other information provided in the notice of denial so that you can determine if you want to appeal the decision.

 

ERISAClaim.com Notes:   You must read carefully specific reasons your insurance company gave when you receive denials. Usually this type of denial notice is called EOB in your doctor's office, Explanation of Benefits. Only reasons given and found on this EOB, Explanation of Benefits, are official and legal grounds for denial. Any payment less than 100% claimed is considered denial, partial denial or total denial. Your denial notice is extremely important because it starts the clock ticking on your appeal rights and legal ground to appeal.

When the decision is made on your appeal, you must be notified of the decision. If your claim is denied, you must be told the reason and the plan rules upon which the decision was based in writing in a manner you can understand. If you do not receive notification of the decision within the waiting period provided for in your plan, you can assume your claim has been denied after it was reviewed.

 

ERISAClaim.com Notes:   Health insurance problems under managed-care are the most frustrating problems faced by the entire nation, but if you understand ERISA law and your plan's claims procedure in the SPD, you can win your most appeals. You must understand ERISA appeals procedure-federal law, every plan and managed-care organization must follow; you must also understand and follow your individual plan's claims procedure from that SPD. ERISA claims procedure-federal law is explained in more details by DOL by clicking here.

 

If you disagree with the final decision on your appeal or if your plan fails to make a timely decision, you have the right under ERISA to file suit in court to get your benefits. The plan's explanation of your denial should describe this right. You also may wish to get in touch with the Department of Labor's Pension and Welfare Benefit Administration concerning your rights under ERISA.

 

 

ERISAClaim.com Notes:   If you really understand and follow ERISA laws, individual plan's claim procedure and appeal denials appropriately, you may resolve most of your dispute. Otherwise you can file lawsuit in federal court. ERISA lawsuit successful rate is mostly depending upon how well you appealed, instead of lawsuit only. Without appropriately completing your appeals as required by ERISA law and plan's appeal procedure in a timely fashion, you will most likely lose in your lawsuit in federal court. If your health insurance is in private-sector and from employment, ERISA, instead of state insurance law, is the governing Law and federal court, instead of state court, is the right place to file lawsuit. You must complete ERISA appeals before filing any lawsuit.