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Filing an ERISA Claim – 5 Common Things to Keep in Mind

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If you have become disabled and unable to work because of a serious injury or long-term illness, you may want to see if you qualify to file an ERISA claim. These benefits cover both short-term and long-term or permanent disability. However, it is important that you understand how it works and the terms and conditions before filing an ERISA claim.

attorney filing an ERISA claim

What Is ERISA?

The Employee Retirement Income Security Act of 1974, also known as ERISA, is a U.S. federal tax and labor law that governs most employer-sponsored benefit and welfare plans. These benefits include health insurance, covering any medical or hospital bills, disability insurance in the event of an injury or accident and set minimum standards for pension plans in the private industry.

ERISA was first formed to protect employees in an organization and to provide a legal framework for dispute resolution and grievance handling that ensures employers adhere to strict guidelines and regulations. 

However, there have been several cases where an employee is denied the benefits of ERISA. IHat’s why, if you are eligible to file a claim, you need a thorough understanding

There are several unique challenges of ERISA claims, including:

  • Your insurer has denied the claim.
  • Your insurer is trying to delay the benefits.
  • The process is slow.
  • Your insurer is questioning the credibility of your case. 

In this blog article, we will discuss the common issues that can happen while filing an ERISA claim and how to prepare for them.

1. Is ERISA applicable in your case?

The first step to filing an ERISA claim is determining whether you are eligible for the benefits. ERISA applies to all the employees of a private sector company and is applicable for these businesses-

Shared partnerships, proprietorships, LLCs, etc. A company working with even 2 employees has to give ERISA benefits to both of the employees. 

NGOs, non-profit, social service and charitable organizations are all covered by ERISA. 

However, there are a few exceptions to it-

  • ERISA does not apply to organizations under the authority or maintained by a church, mosque, temple, etc.
  • Government organizations
  • Plans outside the United States are largely intended to benefit non-residents.

Remember that ERISA claims differ from regular insurance claims and require a complete understanding from both the claimant and the opposite party.

2. Statute of Limitations

When filing an ERISA claim, it is important to make sure you are within the statute of limitations. Just as with other laws, ERISA has specific deadlines for the claimants to file their case.

Courts have set a limitation period of 180 days for a claimant to file an ERISA claim. However, this period is determined by the type of disability insurance policy you currently hold. In case of a failure to appeal timely, you risk losing the right for any future recovery.

Additionally, you are required to try all possible administrative and legal actions before filing a lawsuit. Since these deadlines can vary depending on the type of plan, it is important to consult an attorney beforehand. 

3. Standard of review

There are 2 standards of review governing the ERISA cases- (1) de novo or (2) abuse of discretion. The de novo case is arbitrary, not a preferable choice for the claimant, and is more beneficial for the insurer. It is because the judge does not evaluate the insurer’s initial decision, whether they are right or wrong. Generally, most cases are judged under the abuse of discretion, where the court analyzes the case and asks the insurer to submit the evidence to support them. 

4. Collecting the administrative records

When filing an ERISA claim, the final decision on the ERISA case is based on an administrative record which includes available documents, facts and records analyzed by the plan administrator for the final evaluation. The federal court judge passes a judgment based on the administrative record. These documents include: 

  • The summary plan description.
  • Medical bills and expenses.
  • The current policy.
  • Letter of Appeal.
  • Your job designation and description.
  • The communication between you and the insurer.
  • Insurance documents and records

5. Understanding the benefits of ERISA Claims

ERISA claims entitle you to several benefits which can be complicated to understand. Long-term disability claims can be complex; many don’t provide coverage for an entire month’s salary. It is usually the proportion of your salary. Therefore, when filing an ERSAI claim, it is important to understand the exact benefit value of your ERISA claim.

Final Words

These points must be kept in mind when filing an ERISA claim. It is advised to consult experienced ERISA attorneys to navigate smoothly through the legal process.

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