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What Is ERISA, and What Does It Cover?

Long-term Disability Insurance Attorneys Nationwide

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets national standards for private employer-based health insurance and disability benefit plans. ERISA does not apply to plans purchased by individuals and that an employer does not offer.

The simplest way to understand ERISA is to remember this: If your insurance plan (retirement, health, disability, or other policy) is provided through your employer, ERISA requires your insurance company to abide by certain very minimum requirements. Note that ERISA does not require employers to offer these plans. But, when they do, ERISA governs them.

ERISA is wide-ranging yet very deadline specific and unforgiving. Like other parts of an employee’s benefit package, group disability insurance plans may be subject to ERISA—when the employer provides the plan.

ERISA grew out of a need for increased employee protection, with respect to retirement income security among other things—but today, offers few consumer safeguards. Pertinent parts of ERISA reveal this pro-employee intention. For example, ERISA requires insurers to:

  • Provide accurate plan information to policyholders—what is and is not covered
  • Adhere to standards of conduct for plan managers and other fiduciaries
  • Enforce provisions and limitations that help to shield plan funds so that qualifying beneficiaries receive the benefits to which their plans entitle them.
  • Provide policyholders with directions for how to file disability claims, in the event that a policyholder becomes disabled
  • Provide claimants with an outline of the appeals process, in the event of a denial

Despite noble intentions, ERISA is a complex system that favors employers and their insurers and hinders employees. For employee-policyholders of ERISA disability insurance plans, ERISA establishes strict rules for filing and appealing disability claims, and it sets many requirements for deadlines and submissions.

If you are insured under an ERISA disability insurance plan, ERISA generally requires that you appeal a denial, in writing, typically within 180 days of the denial.

Failing to appeal—according to ERISA guidelines—will negatively affect your ability to file an ERISA federal lawsuit later. Hiring the seasoned attorneys at the top-rated disability insurance law firm of DarrasLaw will ensure that you meet all of ERISA’s many requirements and strict deadlines.

Tell Me More About ERISA

The Employee Benefits Security Administration (or EBSA)—a division of the Department of Labor—administers ERISA. Make your local EBSA office your first point of contact, if you have questions, concerns, or complaints about ERISA.

ERISA laws only apply to non-government, private employers that offer health insurance plans—and other specific benefit plans, such as disability coverage—to their employees.

If you need to pursue a civil claim against an employer-provided plan that falls under ERISA, doing so is tricky, fraught with problems, and complicated. Many lawyers who take ERISA cases work only in this area of the law, so these attorneys—like the seasoned disability insurance lawyers at DarrasLaw—can help employees whose insurance companies may have wronged them by violating ERISA.

The requirements and standards that ERISA sets for insurance companies include:

  • Conduct
  • Reporting and accountability
  • Disclosures
  • Procedural safeguards
  • Financial and best-interest protection

At DarrasLaw, we evaluate group disability claims that fall under ERISA and can provide information about your legal appeal and claim options. To learn more about ERISA, please visit our many web pages dedicated to the subject.

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Need to Know: Appeals and ERISA Group Coverage

Despite its few safeguards, ERISA was originally designed to protect you—the employee. This is comforting, even if it doesn’t make your compliance with ERISA any easier; nonetheless, these hoops are for your protection and not the employer-insurer.

When insurers fail to comply with ERISA requirements, you stand to gain if your plan is ERISA-governed. For example, if your disability claim was denied under an ERISA-governed plan, the insurer is required to provide you with a notice of the denial. In the denial letter, among other things, your ERISA-governed insurer must tell you:

  1. The specific reason for the denial
  2. The insurance plan’s provisions and limitations on which the denial is based
  3. What additional information the insurance company needs to reconsider the original disability claim
  4. How to submit an appeal for the wrongfully denied disability claim

In addition, ERISA includes specific deadlines and guidelines for filing an appeal to overturn the wrongful denial.

Furthermore, ERISA requires that insurers offer certain things to the consumer free of charge, such as the right to appeal.

Other pertinent ERISA appeals guidelines include:

  • Insurance companies must provide at least 60 days for you to file an appeal from the date you received your notice of denial.
  • Whatever deadline your insurer has (60 days, 90 days, 180 days, etc.), it should state this deadline clearly in the notice of denial.
  • Insurers can’t charge you to file an ERISA disability appeal.
  • Your insurance company must make a decision regarding your appeal according to strict ERISA guidelines after receiving your appeal notice. This maximum deadline will vary based on the type and thoroughness of your appeal.

In the event that your insurer informs you of the need for an extension, ERISA provides guidelines for the notice as well. The insurer must tell you:

  • Most basically, that it needs an extension
  • Why it needs an extension
  • Any additional documents or information the insurer may need from you
  • A reasonable time whereby you can expect a decision regarding your appeal

What Happens If My Disability Denial Is Upheld on Appeal?

If, after timely filing your appeal, your insurance company upholds its original wrongful denial, the company must also provide you with specific information related to this appeals decision.

This notice must state:

  1. specific reasons for the decision
  2. the specific provisions and limitations from your policy with the insurer that support its decision.

In the event that an internal appeal upheld a wrongful denial, you still have options. You may sometimes appeal a second time—depending on the specific language and options provided by your policy, and DarrasLaw for help.

If this second, internal-appeal option is unavailable to you, you can still contact your regional U.S. Department of Labor Employee Benefits Security Administration (EBSA) for next steps.

If Your ERISA-Governed Disability Claim Was Wrongfully Denied, Please Contact DarrasLaw Today!

At DarrasLaw, our disability insurance law firm has seen more, evaluated more, and resolved more individual and long-term disability cases than others across the country. If your insurer wrongfully delays or denies your individual or long-term disability claim, we are here to assist and get the disability benefits you deserve.

We evaluate cases throughout the United States. There is no risk involved in contacting DarrasLaw.

The top-rated, compassionate disability insurance lawyers and Los Angeles ERISA attorneys at DarrasLaw have recovered nearly $1 billion on behalf of disabled people just like you—unsure of where to turn. Turn to us.

We can help you when enough is enough. Reach out to DarrasLaw today at 800-898-7299 or contact us online for a free policy analysis or claim consultation.

DarrasLaw is Americas' most honored and decorated disability litigation firm in the country. Mr. Darras has seen more, evaluated more, litigated more, and resolved more individual and group long term disability and long-term care cases than any other lawyer in the United States.

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