The Employment Retirement Income Security Act (ERISA) protects the rights all Texas workers who are covered by a pension plan or a health insurance plan issued by their employer. ERISA mandates the obligations of the employer and the insurer who has issued the plan at issue. If either the insurer or the employer violates these requirements, an employee claim for benefits will be decided according to the plain terms of the plan.

Basic claim procedures

Every plan administrator must give every covered employee a copy of the summary plan description (SPD) and a copy of the plan itself. If the language of the plan conflicts with the language of the SPD, the more favorable document will control. The two documents together will determine whether the plan provides coverage for the employee’s illness or injury.

The procedures for submitting a claim for health care benefits are set forth in the plan and in the SPD. The claim must be in writing and must be supported by the opinion of at least one health care professional verifying the nature of the injury and its effect on the employee’s ability to work. The administrator must either accept or deny the claim according to the criteria set forth in the plan or plan summary.

Appealing a denial

An employee whose claim has been denied may take an appeal to the plan administrator. The claim will be reviewed by fresh eyes who will look at all of the evidence before rendering a decision. If the administrator’s discussion is reversed, the employee will be eligible to receive benefits very soon thereafter.

If the denial is affirmed, the claimant can bring an action in federal court challenging the legal and evidentiary basis for the decision. If either party is dissatisfied with the decision of the district court, it can take an appeal to the Fifth Circuit Court of Appeals. Very few cases go beyond this stage of the appeal process.

Anyone who has filed an unsuccessful claim for ERISA benefits may wish to consult a lawyer who is knowledgeable about ERISA and appellate procedures for advice on whether to continue the case.