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Appealing an ERISA claim

| Jun 1, 2021 | ERISA Benefits Claims Appeals

Even when people have insurance for medical care, there are some instances in which the insurance claim is denied. This can be a difficult situation for patients. When a claim is denied because the service is not considered a medical necessity or the service is not covered by a patient’s insurance company, it’s best to learn about ERISA claims. If you’re a Washington, D.C., resident, here are some things to know about a self-funded ERISA plan.

What is ERISA?

Congress passed ERISA, or the Employee Retirement Income Security Act, in 1974 to protect employer-sponsored health and retirement plans. It can be difficult to determine if a patient has an insurance plan that is in keeping with ERISA law. This is because a BCBS network can be used for paying claims according to ERISA policies or non-ERISA policies. ERISA claims are only limited to plans that are self-funded by private employers. Non-private plans funded by public schools, government organizations, churches, military and individually purchased insurance are not covered by ERISA law.

What are self-funded plans?

If an employer has an insurance plan that is self-funded, the plan covers the cost of each claim. This is different from a full insurance plan in which the employer pays premiums to the insurance company and the insurer offers coverage to the employee and the employee’s dependents. If an employer chooses a self-funded plan, the employer may not be able to make ERISA claims. Self-funded plans require the employee to assume the risk of payment benefits; however, there is usually a larger cash flow for a self-funded plan.

ERISA laws set the standards for the methods in which self-funded private employee health insurance plans are administered and how claims are processed. These laws also determine regulations for appeals. Beneficiaries can appeal if they are denied treatment or if their ERISA claims are denied and unpaid.

Speaking to a qualified lawyer may help you determine the best steps for appealing your ERISA claim. A successful appeal may mean getting the funds you’re entitled to.