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If you, like many Americans, are grappling with ERISA and how to navigate the system, you are not alone. Let’s begin with the beginning.
ERISA is more formally known as the Employee Income Retirement Security Act. It is a set of minimum standards for employers who offer employee benefit plans (including retirement plans, health benefits, life insurance, and disability insurance). This includes:
Transparency: ERISA stipulates that employees must be given information about their pension plans and other benefits. For each benefit plan offered, employees must be notified on how to file claims for their benefits. They must also be notified of deadlines and standards required to make a claim for their benefits, as well as any important changes. This information must be provided in writing, either automatically or upon request.
Protection from Wrongdoing: ERISA also protects employees from any wrongdoing or mismanagement by “plan fiduciaries”, which basically means anyone who has authority over benefits plan management (like plan administrators or trustees).
ERISA does several things for employees, including establishing a federal pathway to challenge benefit denials. If you attempt to claim a benefit you believe you are entitled to by your employer and you are denied, ERISA allows you to appeal that denial under federal law.
This is one solution to a major loophole that formerly existed for employees in the US. Before ERISA, if you had a benefits claim wrongly denied, there was no real way on the state level to sue your employer’s insurance company for bad faith. ERISA (and other federal laws like it) “pre-empt” or take precedence over state laws. It therefore creates a federal way to file a lawsuit against an employer’s insurance company. This allows employees to exercise their right to benefits, as promised to them by their employer.
If your ERISA appeal is successful, you will be entitled to receive all benefits for which you are eligible, as set forth in your employer’s insurance policy.
Navigating the ERISA process can be very complicated, especially if you are attempting to do so on your own. It involves a very thorough investigation of benefits plans and procedures, which can be difficult if not impossible for a layperson to do on their own. However, with the help of an experienced, knowledgeable ERISA attorney, the process can be relatively painless and quite simple.
The ERISA process starts when you are wrongfully denied benefits by your employer’s insurance company. The insurance company will send you a denial letter, stating their reasoning. From there:
1. You will take your denial letter to an ERISA attorney, who will closely review and examine it.
2. Your ERISA attorney will access your claims file, which formed the basis for the denial. They will also closely examine the benefits policies laid out by your employer and their insurance company.
3. Your ERISA attorney will analyze whether your claim denial could be considered wrongful or inappropriate, and whether ERISA is the right remedy. Usually, they will be looking for evidence of breach of contract, negligence, bad faith, misrepresentation, or fraud.
4. Your ERISA attorney will also review the supporting documents you submitted along with your claim, and make sure all existing documents are in proper form. If there are any potentially helpful documents missing, your ERISA attorney will help you add them to bolster your case.
5. If the denial was indeed wrongful, your ERISA attorney will highlight exactly where and how the insurance company made a mistake in denying your claim. They will then file an appeal under ERISA.
6. Your ERISA appeal will be adjudicated, and a Decision will be made.
Have you or a loved one been denied benefits by your employer or their insurance company? Are you trying to navigate the ERISA process or looking into your options for claims appeals through ERISA? Are you in Warwick, Rhode Island? If so, Warwick ERISA Attorney Mark Morse is ready to help. Attorney Morse has extensive experience in ERISA cases. He has the knowledge, skill, and tenacity to take your case all the way through the process, from start to finish. He will give you the best possible shot at claiming the benefits that you deserve. Don’t wait! Call the Morse Law Office at (401) 831-0555 for a free consultation today.