Many New Jersey residents are participants in group plans offered by the companies that they work for and that are governed by the provisions of the Employee Retirement Income Security Act. Despite its name, ERISA covers more than just retirement plans, and the 1974 federal law also encompasses health and disability programs. There are a variety of rules and procedures that come into play when submitting a claim, and if a claim is denied, Claimants must generally first go through an administrative appeal to the insurance company or plan administrator. If the appeal is denied at that stage, the employee can then file a lawsuit against the plan in federal court.
Lawsuits resulting from claim denials
Claimants who file a lawsuit are not entitled to a jury trial. Instead, the case is heard by a judge. The court will make its ruling based upon the facts that have been collected during the administrative appeal. If the plaintiff is successful, the court is permitted to award reasonable attorney’s fees. However, it is very rare for the plaintiff to be assessed attorney’s fees if the claim is denied at this level.
Disability claims and pre-existing conditions
It is not unusual for a ERISA disability benefits claim to be initially rejected by the plan administrator and the insurance company that provides the coverage. One reason that is sometimes cited is that the employee had a pre-existing condition that results in a coverage exclusion. In this regard, the language of the plan can be confusing and complex, and claimants should seek the advice and counsel of an experienced insurance attorney when this is the case. The law states that people who are denied benefits are entitled to a fair and impartial administrative review. The facts placed on the administrative record will be considered by the judge when making its decision.