If Your Insurance Claim Is Subject to ERISA — BEWARE
ERISA controls all insurance provided through employer-sponsored benefit plans. For most working people, this means all of their health, disability, and life insurance claims are governed by ERISA, a federal statute that is a disaster for consumers.
Bob Rutter has written an article entitled "Taming the ERISA Beast: Contesting the Denial of ERISA Insurance Claims" which addresses the problems and pitfalls that arise in ERISA claims.
If you have received a denial of an insurance claim and the letter states that your claim is subject to ERISA, then BEWARE. A wrong move can jeopardize your claim, regardless of the merits of your claim. Do not try to handle a wrongful denial yourself. Speak to a lawyer who knows and understands ERISA's complexities — NOW.
A company executive in Ohio was diagnosed with a rare and disabling condition within the first year of starting a new job. There was no question that the insured was disabled, so the insurer tried a common tactic — asserting that the disease was a pre-existing condition (PEC). The claim was denied and the insured came to Rutter & Russin for help. Knowing the rules governing ERISA claims, Rutter & Russin demanded an administrative appeal, obtained the administrative record, reviewed the report from the defense doctor, and successfully argued that the carrier's interpretation of the PEC exclusion was incorrect. After months of wrangling, the carrier finally backed down and paid the claim in its entirety.
Before coming to see Rutter & Russin, the beneficiaries of a life insurance policy had been getting nowhere with the insurance company for over a year. Their mother had died of complications from Alzheimer's, and the claim had been denied because the mother had failed to pay the premium about six months before her death. The insurer recognized that the deceased had Alzheimer's, but argued that one of her daughters, a beneficiary under the policy, was charged with the duty of handling her mother's affairs. Rutter & Russin succeeded where the beneficiaries had failed and the claim was paid in full within a few months of the firm's involvement.