Federal law regulates employee-funded insurance policies

Erisa Attorney San FranciscoThe Employee Retirement Income Security Act of 1974(ERISA) was passed by Congress to ensure retirement and health plans would provide millions of Americans access to qualifying financials when they needed it.

Navigating through the process of filing an ERISA claim in the Bay Area can be a tedious, frustrating experience, especially if you are already in pain or discomfort from a personal injury or illness. The team of experienced California insurance law attorneys at DL Law Group is dedicated to representing workers in San Francisco, San Jose and the surrounding communities who are seeking to file an insurance claim through an employer-funded insurance company.

When serious injuries and illnesses keep workers from performing their job for extended periods of time, the insurance benefits they receive from insurance policies obtained through work is designed compensate for any time missed on a short-term, long-term, or permanent basis. The federal government took action by passing ERISA to set minimum standards that protect employees.

  1. What is ERISA?
  2. Why was the ERISA insurance law enacted?
  3. Which plans are governed by ERISA insurance law, and which are not?
  4. When can ERISA disability claims be filed?
  5. Can my ERISA claim be denied?
  6. Can pursuing an ERISA claim jeopardize my job?
  7. Can I file a bad faith claim under ERISA?
  8. What is the appeal process for denied ERISA claims?

What is ERISA?

ERISA is a federal law enacted in 1974 designed to protect the rights of workers in employer-sponsored benefit plans.  Minimum standards were set for benefit plans with private employers.ERISA provides protection for workers in the private sector by:

  • Mandating those insured receive full disclosure of all insurance policy information
  • Establishing a code of ethics for administrators of insurance plans
  • Providing federal court access and legal representation to settle disputes

Long-term disability policies provided by private insurers are regulated under ERISA insurance law. Serious injuries or long-term illnesses may qualify you to file an ERISA claim to cover a short- and long-term or permanent disability.

Why was the ERISA insurance law enacted?

The U.S. Congress had concerns that the money accumulating for the funding of employee benefits could be mismanaged and employees would fail to receive their proper benefits when they needed them. ERISA imposed a set of requirements for the participation, funding, vesting, and enforcement of employee benefits rights. Uniform standards and safeguards were put in place to protect the integrity of reporting, disclosure, handling of claims, and the fiduciary responsibility.

Which plans are governed by ERISA insurance law, and which are not?

Employee-sponsored insurance plans that may cover health, disability, retirement, or life insurance benefits are governed by ERISA if the plan can reasonably be defined as covering “employee welfare benefits.”  The two main exceptions involve religious employment where benefits are provided through a church or temple, and public employment. Government employees are not subject to ERISA laws.

When can ERISA disability claims be filed?

In the case a disabling injury or illness that renders you unable to perform your job duties and responsibilities, ERISA claims are evaluated by your employer and/or insurance company. Some coverage plans define disability as the inability to continue with a job specific to your current occupation, while others see it as not being able to work at all in any occupation.How your insurance company defines “disability” can change your approach to and the results of filing a claim.

Can my ERISA claim be denied?

ERISA regulation allows for administrators of long-term disability claims to either approve or deny your ERISA claim. You have the right to appeal if the claim is denied and if the appeal is denied, a qualified ERISA attorney can facilitate a lawsuit against the administrator.If a long-term disability came from a work-place injury or illness, your claim may not be covered under ERISA insurance law. If you suffer a work-related injury that results in long-term disability, you will need to file a workers’ compensation claim.

Can pursuing an ERISA claim jeopardize my job?

Pursuing an ERISA claim should not put your job in jeopardy. ERISA regulations specifically prohibit retaliation from employers to employees filing a claim under ERISA. Your employer cannot fire you or deny you a promotion or bonus based on any taken regarding your health benefits.

Can I file a bad faith claim under ERISA?

The quick answer is no, bad faith claims cannot be filed under ERISA. If your disability benefits claim has been mishandled, a separate fraud claim may be filed against certain kinds of defenders, though many common law fraud claims are also pre-empted by the ERISA unless it can be proven that a duty outside the realm of ERISA regulations has been violated.Courts all the way to the Supreme Court have maintained the ERISA provision that prohibits workers to file bad faith claims since the law was originally passed.

What is the appeal process for denied ERISA claims?

The process of appealing an ERISA claim decision is a complicated, inefficient and lengthy process. Cases of administrative appeals can sometimes take up to a year. If you have reached the point where you need to appeal a denied ERISA claim, contact a San Francisco area ERISA attorney to make sure you are being properly represented and protected.Procedures for appealing benefits claims can be different from plan to plan. Evidence to present that will support your claim can include relevant medical records, doctor reports, and vocational expert opinions.  A written decision will be delivered with the appeal decision with an outline of the reasons the appeal was accepted or denied.

If your appeal is denied, there are no other courses of action to take except having an experienced ERISA attorney file a civil lawsuit against the defendants on your behalf.

Contact an ERISA Attorney at DL Law Group

If an injury or illness kept you out of work in the San Francisco Bay Area and you need to file an ERISA regulated insurance claim from an employer-funded policy, contact a qualified representative at DL Law Group experienced in California ERISA insurance law to discuss your case. Call toll free (415) 678-5050 for a free consultation.