Many employees treat health insurance plan paperwork as they do heat and air conditioning: They disregard them until an emergency arises. A federal law known as the Employee Retirement Income Security Act (ERISA) regulates employer-provided health insurance. Though the act’s name emphasizes retirement plans, numerous provisions address employer-sponsored health plans other employee benefit plans through which participants file claims to receive benefits.
Data provided to Congress by the Department of Labor (DOL) in 2018 stated that more than 2 million ERISA-covered plans covered approximately 136 million people in 2015. Administered and enforced by the DOL, ERISA mandates minimum standards for health insurance plans offered by private sector employers. Among the requirements: The insurer must administer the plan in accordance with a written plan document.
Court matches specific facts against the language of the plan
Provisions of the written plan must describe procedures for processing benefit claims and appeals.
This issue arose during a recent court case before the U.S. District Court for the Western District of Texas. A truck driver involved in an accident while performing work functions asserted multiple claims under the employer’s plan covered by ERISA. The court granted the employer’s requests that no legal issue existed on all issues but one: a wrongful denial of benefits.
Under the specific ERISA provision, the plaintiff had a right to benefits promised but not provided under the employer’s plan. The court determined the third-party claims administrator that denied the initial benefits request did not read the plan fairly. A reasonable jury could interpret the plaintiff’s attempts to comply with the separate requirements of reporting and furnishing of information as adequate.
Patience throughout the process
Those that fall under the umbrella of ERISA demand attention to detail concerning notification to proper individuals or entities, filing deadlines and the specific provisions of the health plan. Attorneys familiar with these issues common can provide guidance.