Being insured is important for residents in Texas and elsewhere. With a traditional insurance company, a claim is filed based on the terms of the insurance contract. Thus, if an insurer refuses to pay a claim for a benefit, it is possible for them to file a suit in state court for breach of contract. However, when a claim is filed under Employee Retirement Income Act of 1974 or ERISA, the process is much different for the insured when a claim is denied.
Filing an ERISA claim
For an ERISA claim, there is a timeframe to file a claim, and this is based on the type of claim. Additionally, because decisions are often time sensitive, certain decisions have set deadlines. These claims include urgent care claims, pre-service claims, post-service claims and disability claims.
If a claim is denied, the notice has to include five things. This includes the specific reason for denial, the plan’ provisions for which the denial is based on, any additional information what might be necessary for them to consider the original claim, steps to file an appeal review and how to file an external appeal for non-grandfathered plans.
Appeal process
The procedures for an appeal are outlined by the insurance plan. This will detail set deadlines to file an appeal. Much like the claim decisions having set deadlines for decisions, appeals have these same standards. In general, this should not be more than 60 days after the appeal is received.
When a decision is arrived at, the appeal decision must be given to the insured in writing. It must also give them the specific reason for the decision and reference to the specific provisions in the plan for which the decision is based on.
If an appeal is denied, the next step would be to file an appeal with the insurance company for a second time. Another option would be to file an appeal through one’s regional Employee Benefits Security Administration or EBSA.
Going through the claims and appeals process can be overwhelming and complex. In some cases, it can be difficult to handle multiple appeals for the same claim. Thus, it is important to understand one’s legal options, as it could help them navigate the process and obtain favorable outcomes.
