Those individuals who receive employee health insurance through a group benefits plan have certain rights and protections. A 1974 federal law called the Employee Retirement Income Security Act (ERISA) affords insured individuals these protections.
Those individuals covered under group benefits plans include yourself, dependents such as children and your spouse. ERISA allows you to remain covered even if you would typically lose health insurance benefits because a qualifying life event occurred.
As a side note, group benefits coverage doesn’t extend to domestic partners nor their dependents unless the insurance company explicitly decides to allow those individuals to be covered.
ERISA establishes that you have a right to know why your health insurance provider denies your claim. You are entitled to receive copies of written documents used to make that decision at no cost.
You also have the right to appeal any denial of benefits so long as you meet specified filing deadlines. You can file suit in either state or federal court. If your claim was denied based on discrimination or misuse of the plan’s funds, then you may seek additional assistance from the U.S. Department of Labor.
You can file a lawsuit in federal court if your insurance company doesn’t honor your request to provide you with the latest annual report or copy of the plan document within 30 days. The plan administrator may be required to furnish the court with the requested materials and fined until they submit such documents. Your plan administrator may be able to avoid fines if they can demonstrate a valid reason beyond their control that prevented them from providing you with the documents in a timely fashion.
If you have been denied benefits under ERISA, then you have a right to appeal that decision. You may be entitled to monetary compensation if you win your Washington, D.C. case. An attorney may help you recover the costs associated with your denial and other related damages if you are victorious at trial.