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  • Writer's pictureBrandon S. Peters, Esquire

Insurance Claim Denials - ERISA Policies

Health Insurance policies are available to consumers under two broad categories: ERISA and non-ERISA. This week, we’re going to discuss health insurance claim denials for ERISA policies, which are governed by the The Employee Retirement Income Security Act of 1974.

ERISA is a federal law that sets minimum standards for most employer-sponsored retirement and health insurance benefits. In general, ERISA does not cover group health plans established or maintained by governmental entities, churches for their employees, or plans which are maintained solely to comply with applicable workers compensation, unemployment, or disability laws. It also doesn't cover private health insurance plans which provide coverage to individuals not as a benefit of employment.

Claims can be denied for a number of reasons: The treatment was not medically necessary; the medical condition was not covered by the plan or was preexisting; a misstatement appears on the insurance application; or the medical claim was made fraudulently.

Unlike some other types of insurance plans, ERISA litigation requires plaintiffs to seek a remedy for insurance claim denials through at least two administrative appeals before taking the insurance carrier to court. Under federal law, these types of cases are subject to different standards than regular contract law cases so it’s important to have an attorney review your denial letter immediately and start working on your appeal.

If you’ve received a letter denying your health insurance claim under a policy provided to you as an employment benefit, please contact us today!

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