Getting injured, no matter where or how it happens, is a terrifying and frustrating experience, but it can be especially upsetting if you find yourself unable to work and not covered by workers’ compensation. However, for some workers, there’s another option than workers’ compensation: ERISA plans.
These voluntary plans offered by some employers as part of a benefits package are governed by the Employee Retirement Income Security Act of 1974, which guarantees minimum benefits of voluntary insurance and retirement plans in the private sector. An ERISA plan will help to cover your bills while you recuperate, helping you maintain your standard of living, and it may extend all the way to your retirement if you are permanently disabled. Unlike workers’ compensation, it has no requirement for the injury to be work related, though many ERISA plans have strict stipulations on what kinds of injuries they will cover.
Filing these claims, though similar in many ways to filing any other insurance claim, can be incredibly difficult and confusing, which is why working with an ERISA disability lawyer is the best way to ensure that your claim is approved and you receive the compensation to which you are entitled. Today, we’ll discuss the process of filing an ERISA claim, then explain how a disability lawyer can assist you in this complicated process.
First, gather and fill out the ERISA forms
As an ERISA plan is provided by your employer, you should first contact the department responsible for administering your benefits, explaining that you’d like to file a claim. They will direct you to where to gather the forms, whether that is through a self-serve portal in an online benefits management program, or through their insurance company’s website.
These forms will ask for information such as your disability, medical treatments, and work history. Some disabilities may not be covered by the specific ERISA plan your employer offers, and they may only approve payment for specific medical treatments that are determined as medically necessary by their adjusters. Similarly, you may only receive benefits after working with your company for a certain period of time; so, for example, if you were in a car accident shortly after joining a company, you may have your claim denied.
Gather and include all relevant medical information
As you might expect, the ERISA claim will require a great deal of information about your health: any previous conditions that may have contributed to the disability, when and how the health issue was diagnosed, and what treatments you have undergone so far.
You’ll need to give detail from before the accident as well, because some ERISA plans can deny a pre-existing condition. This is because, unlike regular health insurance, they are not beholden to the Affordable Care Act stipulation that pre-existing conditions must be covered.
Submit your ERISA claim and wait for a decision
Once you’ve gathered all the information required by the forms, you’ll submit them to the insurance agency and wait to hear a verdict. The Employee Retirement Income Security Act requires that insurance companies process claims in a timely manner, so you should receive some communication from them within 45 days.
If they need more information, the insurance company will send you a detailed response explaining what they need from you; they will then have to make a full verdict within 30 days of sending you that request, for a total of 75 days from submission to verdict. The company will then have 90 days to provide your first payment from the day of the claim’s approval.
However, you may be denied, either before providing more information or after. This is when the appeal process begins – and exactly why you need a lawyer with you at every step of the way.
You can appeal a denied claim, and the insurance company will explain how
If you’re originally denied your ERISA benefits, don’t despair: you have the opportunity to appeal the denial. Depending on the plan and the reason for denial, you may simply submit more information, or you may have to appear at a hearing.
The insurance company will give you step-by-step instructions on what to do next, including what additional information they need to make their decision. However, don’t believe that this means that you should go this alone: disability lawyers are essential during the appeals process.
A Cincinnati, Ohio, ERISA disability lawyer can help you gather the appropriate information to receive an approval, and they can help you make sense of the insurance company’s instructions, which can be quite confusing – especially when you’re already injured and frustrated by the denial.
Your ERISA lawyer will join you at the hearing and represent you in the best light, presenting your claims and using the evidence available to prove that your claim meets the standards laid out by the insurance company’s requirements. They’ll also be able to negotiate with the insurance company, ensuring that you receive exactly what you’re entitled to and not a penny less.
While the ERISA claim process may seem straightforward, don’t be fooled: there are numerous ways that your legitimate claim may be denied through no fault of your own. If you’ve been disabled and are entitled to ERISA benefits, you must contact a qualified disability lawyer in Cincinnati, Ohio, to ensure that your rights are protected and you receive the assistance you deserve.