ERISA Insurance Claims

The Columbia insurance attorneys at the law firm of Gump & Faiella, LLC are ready to assist you if you have been denied your rights or have had your claims denied under an accidental death, life insurance, or disability plan through your employer. The Employee Retirement Income Security Act (ERISA) is a federal law that sets minimum standards for pension plans and welfare benefit plans established by private employers.

ERISA’s main goal is the protection of plan holders and the beneficiaries of those plans. ERISA does not regulate plans set forth by government agencies or churches. Although ERISA does not require employers to provide pension or welfare benefit plans, the act does regulate those employers who do provide these plans. The standards set forth by ERISA govern participation, vesting, and funding.

Types of Insurance

If you have an accidental death plan, life insurance, or disability insurance under a group plan through your private employer, it is most likely governed by ERISA. ERISA requires that a policyholder (employee) be informed of the state of the plan and their rights under it and that a policyholder has the right to sue in court for benefits withheld or denied unfairly. Although ERISA was designed to ensure that an employee receives the benefits they have earned and are entitled to, that does not always happen. Many of the rules of ERISA stack the deck against the claimant seeking benefits and in favor of the plan and its insurer. ERISA also impacts the ability to bring a claim in court by changing the legal standard and supplanting state law with federal law.

Obtaining Benefits

To successfully obtain benefits it is important to seek counsel as soon as your claim has been denied. Our attorneys can help you with the claims appeal process, including obtaining the medical, factual, and legal support for your claim. This is a critical step, because the insurer may reverse their decision and grant benefits if they are convinced of the claim.

This step is also critical because if the insurer continues to deny your claim, the materials submitted in the appeals process become the foundation of the claim for a court to review. If facts are not made part of the appeals process when they could have been, it is likely they will not be considered by the court. Thus, working up the claim with all of the facts and legal support is necessary to create a record for a court once litigation begins.

What Can You Do About Denied Claims?

If the insurer denies the claim our attorneys can initiate a lawsuit to recover the benefits to which you are entitled. Our firm will pursue all available avenues of discovery and investigation. We will investigate the doctors or experts used by the insurer to deny your claim. Often the opinions and recommendations of the doctors that actually treat and care for the patient are ignored.

Insurance companies have the time and resources to find vendors who will review claims closely for anyway to avoid having to pay a claim. In other cases insurance companies use medical experts, many who have never examined the patient, to obtain opinions favorable to the insurance company so claims can be denied. We will investigate whether there is a conflict of interest, biased or unfair claims practices of the involved insurance company. If an insurance company has a history of biased claims administration, your claim may have been denied, even though it should have been paid in full.

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