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ERISA appeals are complex

| Dec 21, 2020 | ERISA

Private insurance is insurance from a self-funded employer. When the time comes to file a claim to access the benefits of an insurance policy, many New Jersey workers find it surprising and disappointing when the company denies the claim. The claimant can accept the company’s determination and move on or decide to pursue an appeal. However, the appeal process is complex and precise in nature, and you may lose benefits if the proper documentation and information are not included.

ERISA establishes the guidelines

The Employee Retirement Income Security Act (ERISA) is a federal law that sets the standards for the administration of self-insured, private health insurance plans. ERISA plans also include disability and life insurance plans and imposes fiduciary obligations on the insurers, who are often also the claims’ administrators.

Upon denial of the initial claim, two fundamental considerations come into play. First, administrators must determine if ERISA applies to that specific claim. Second, they must review to ensure that the relevant deadline for the appeal has not expired.

Specific documentation is required

If the appeal is proper, it is necessary to fully develop the administrative record for the appeal process. If a lawsuit is subsequently required, the court will only permit the record of the appeal for consideration. The documents needed for appeal include:

  • A statement indicating the filing of an appeal
  • The complete file submitted for the claim in the underlying denial
  • All relevant medical evidence
  • A narrative from the treating physician covering why the denial decision was erroneous
  • A narrative from the claimant discussing how their condition affects them
  • Narratives from family, friends and co-workers who understand the claimant’s condition
  • Any documents supporting evidence of the claimant’s condition, such as workers’ compensation or social security disability

Court action may be required

Once the administrator receives the ERISA appeal, they have 45 days to render a decision. Upon denial of the appeal and exhausting all administrative remedies, litigation may be an option.