ERISA and Insurance Claims

E.R.I.S.A., Employee Benefits and Insurance

There are a various types of employee benefits that employers routinely provide their employees. The benefits can be through an insurance plan or by way of a plan that is self-funded by the employer. An insurance plan is one where there is actually an insurance policy issued to cover claims. A self-funded plan is a plan where the employer has set aside a pool of money and placed it into an account for the purpose of covering various types of claims or where the employee pays claims from its' general assets. Various types of coverages provided by way of insurance and self-funded plans include long term disability benefits, short term disability benefits, health insurance benefits, dental insurance, life insurance, accidental death and dismemberment insurance, severance benefits, and several other types of benefit plans.

Not only are there countless types of plans, but there are various laws that apply to the different plans and types of claims. The law which most frequently applies to benefit claims is "E.R.I.S.A." which stands for the Employee Retirement Income Security Act. E.R.I.S.A. is a federal law found at 29 U.S.C.S. § 1001 et. seq. E.R.I.S.A. has an administrative scheme that must be adhered to in the event a claim. If your claim is denied under E.R.I.S.A.. You will be sent a letter explaining the reasons why and you will be invited to appeal the denial. You will only be given a limited amount of time within which to lodge your appeal. If you fail to properly or in a timely way appeal the denial then your claim will be very seriously jeopardized later. Additionally, with an E.R.I.S.A. claim, it is often the case that the administrative review and appeal is the most important step of the case as such is where the "administrative record" is developed. If you have an E.R.I.S.A. benefit claim that has been denied then you should seek counsel of your choice to assist you with the appeal of the denial and you should not wait until the appeal is concluded to seek counsel. If your administrative remedies are exhausted (i.e., your appeal is denied) before you procure the services of an attorney then that attorney that you retain at a later date may very well have his or her "hands tied" in handling your lawsuit that is filed with the court. You should have an attorney handle your case beginning with the appeal stage. However, if your initial claim has not been denied then you usually will not need an attorney to represent you until your claim is first denied.

Not all benefit claims are governed by the law of E.R.I.S.A. E.R.I.S.A. does not apply to employees of governmental entities. State, county and local government employees, in South Carolina, are provided various insurance coverages. However, State employees' claims are usually covered by the South Carolina Administrative Procedures Act which is found at S.C. Code Ann. § 1-23-380 et. seq.. The South Carolina Administrative Procedures Act works very similarly to E.R.I.S.A. and has its' own complicated administrative workings. If an appeal is not made correctly or if a deadline is missed then the result will be that the claimant will likely no be able to pursue their claim further. Therefore, it is very important with State employee claims that counsel be procured immediately upon a denial of a claim.

Federal employees are also provided benefits including health insurance, life insurance, long term disability, etc. Federal employees' claims are governed by a set of statutes including the Federal Employee Health Benefits Act. Federal employees' claims are governed under a different set of administrative schemes. Like E.R.I.S.A. and State employees' claims, there are strict requirements and time constraints as far as denied claims one concerned and you should obtain counsel as soon as you learn that your claim is denied. Failure to act in a timely way on a denied claim or to act properly on a denial may hurt your claim to the point that you cannot pursue it.

For those folks who have private or individual insurance policies their claims are not governed by one of the aforementioned statutes. There are other laws that may apply. The most prominent set of other laws that would apply to insurance claims would be the common law of the State of the insured residence. If an individual has a private policy of insurance that is not provided through an employer then it is likely that the person's rights will be governed by State substantive and common law. Various State's laws are very different and there are various remedies available under a particular State's law. State law has certain statute of limitations issues and other time deadlines and requirements that must be adhered to. If a person does not act timely and misses a statute of limitations then the person's right to pursue the matter will be forever barred.

If you have any questions, inquiries or desire representation or counseling with regard to any of the foregoing types of insurance, benefits or claims, please send such communications to rhoskins@fosterfoster.com or call and ask for Rob Hoskins at (864) 242-6200.

To view the firm's history and experiences with E.R.I.S.A. and insurance claims, click rhoskins@fosterfoster.com.