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The ins and outs of the ERISA claim and appeal process

On Behalf of | Mar 9, 2021 | ERISA Claims | 0 comments

Many employees in Texas receive benefits, such as health insurance, from their employers. Thus, when issues arise related to their health insurance claims, this may cause an employee to question whether he or she could file an action to ensure his or her rights are protected and provided. These situations could give rise to an ERISA claim, especially if one believes that their benefits were unjustly denied. Even if an initial claim does not yield positive results, it is still possible to get such results through an appeal action.

Basics of an ERISA claim

When filing an ERISA claim, it is important that one first checks the Summary Plan Description. This should detail whether the insurance plan includes benefits for which he or she is filing a claim. Additionally, this will outline the requirements beyond filing a claim in order to receive health services.

Within a set period of time, insurance companies will make a claim decision. This is generally within 90 days; however, there are specified timeframes for specific types of claims. For urgent care claims, this is 72 hours, for pre-service claims, this is 15 days, for post-service claims, this is 30 days and for disability claims, this is 45 days.

If a claim is denied, a notice must be provided. This notice must provide specific information, such as the reason for denial, the plan’s provisions the denial is based on, the additional information that might be necessary to consider the original claim, how to submit an appeal review and how to file an external appeal.

Filing an ERISA appeal

If one’s claim is denied, he or she has the right to appeal the decision. The plan should explain how this procedure works and this information should have been provided with the denial notice. This typically includes requesting for a review in writing, having a review of relevant documents and submitting issues and comments in writing.

Much like the original claim has a set timeframe, an appeal decision should be made no later than 60 days after it is received. However, if an extension is filed, a decision must be made within 120 days. The final decision must be provided in writing and must give specific reasons for the decision and reference the plan’s provisions that the decision was based on. If the appeal is denied, one could contact the U.S. Department of Labor or seek legal assistance to file an action.

The complexity of ERISA can make it challenging to navigate on one’s own. Thus, it is imperative that one consider the options they have and how best to move forward in the matter. This not only means exploring the options available and the rights afforded to them, but it also means understanding the timeframe one has to file such actions or appeals.