Insurance benefits essentially operate as a contract between the policyholder and his or her insurance company. The policyholder pays premiums over time in exchange for coverage later if needed. However, this contractual understanding leaves many individuals shocked when their claims later get denied.
Insurance companies must weed out invalid claims to protect the insurance pool. However, they may also engage in bad faith tactics to intentionally deny valid claims. In this situation, the policyholder may file a bad faith lawsuit for damages. However, this option is only available to people with certain types of policies. Below, our insurance lawyers in San Francisco explain bad faith claims under ERISA.
Individual Insurance Policies vs. Group Plans
The type of insurance plan you have directly effects your options for disputing a bad faith denial. You should determine whether your plan is an individual policy or a group plan.
An individual insurance plan is not purchased through a group or employer. Typically, individuals purchase individual policies if they are contract workers, self-employed or desire supplemental benefits. Individual insurance plans are subject to state laws, including laws about bad faith practices.
Plans purchased through a group or employer, however, are subject to a federal law called ERISA. Within this law is a provision about preemption. Essentially, ERISA pre-empts, or trumps, any state laws about the benefit plan. This means that plans subject to ERISA do not play by the same rules as individual plans when it comes to bad faith claims.
Can I File a Bad Faith Claim Under ERISA?
While ERISA was initially designed to protect certain workers’ benefits, the law does not protect policyholders against bad faith. In other words, you cannot file a bad faith claim under ERISA.
This means that your options for overturning a denied claim differ in significant ways if your policy is governed by ERISA. Further, recoverable damages are significantly limited. ERISA damages only include the amount owed under the insurance contract, and sometimes attorney’s fees. An insurance company is not punished for getting caught denying a group policy claim in bad faith. They must pay out what they should have paid out originally.
Can I File a Bad Faith Claim Under an Individual Policy?
State laws cover individual policy claims for a breach in contract. This means states can hold insurance companies accountable for engaging in bad faith practices in regard to a contract. Damages awarded in these cases may include:
• Punitive damages
• Attorney’s fees
• Awards for other costs
• Prejudgment interest
Secure Your Insurance Benefits With Help From a San Francisco ERISA Attorney
While pursuing a bad faith claim under ERISA is not possible, you still have options. Your best bet for overturning a denied claim is to work closely with an experienced ERISA attorney.
After a denied claim, your next step is to appeal the decision, but the appeals process is also subject to ERISA. The appeals process is your very last chance to submit new evidence for your claim. If your appeal fails, then you can sue the insurance company, but your suit cannot introduce new evidence. For this reason, you will want an experienced San Francisco ERISA attorney on your side.