Erisa Claims

ERISA Claims: How to File them Easily

Moving forward with an Employee Retirement Income Security Act (ERISA) claim can be quite complex. There are numerous procedural steps and intricacies that may pop up along the way that many do not expect. For this reason, it is important that anyone interested in filing an ERISA claim not only understands the initial claim process, but also how denied claims and the appeals procedure works.

Filing the Initial Claim

In most cases, an ERISA insurance claim is started by making a formal filing with the company. This occurs if your employer has a self-insured insurance plan. If you aren’t sure whether they do or not, you can contact your personal insurance company or the human resources department at your place of work. While in some extenuating circumstances you may be able to file a claim over the phone, this is typically not allowed. Here is a look at the typical steps taken to file an ERISA claim:

  • Contact either your insurance company or the human resources department at your place of work and request their ERISA claims procedure in writing
  • At this point, your insurance company will send you the ERISA claims procedure in writing
  • You will file a claim based on its type: urgent/medical care, preservice, postservice, or disability
  • Your insurance company will let you know if your claim has been approved or denied
  • If it was denied, you will file an appeal before the deadline
  • Your insurance company will review your appeal and either approve your request or deny it
  • If your appeal is once again denied, you can file an additional appeal through the Department of Labor Employee Benefits Security Administration (EBSA)

Timing Matters

You will receive notification regarding the insurance company’s claims decision based on the type of claim field. In most cases, the insurance company has 90 days to provide you with benefits. The initial claims process can take anywhere from one to four months to complete. There are a few specific deadlines and timeframes you should be aware of regarding the different types of ERISA claims:

  • Urgent care/medical claims – 72 hours
  • Preservice claims – 15 days
  • Postservice claims – 30 days
  • Disability claims – 45 days

Can I Get an Extension?

In special circumstances, you may be able to ask for an extension in filing your claim. There are several reasons this could occur, like if your insurance company needs additional information. The extension period will vary depending on the type of claim. Please contact Attorney Janovsky for more information about this.

Denied Claims and The Appeals Procedure

In the event your claim has been denied, you will either be notified by mail or email. The denial notice will include the following:

  • The reason for denial
  • What additional information may be helpful for the insurance company to consider the original claim
  • What steps must be taken in order to submit a denied claim for an appeal review
  • How to file an external appeal

Once you have submitted an appeal, it is your insurance company’s job to include a full and fair review of the claim. In the event your claim is denied, you have the right to appeal this decision. In order to file an appeal, you will need to follow the written plan provided by your insurance company. In many cases, there is a deadline for you to appeal the decision – 60 days from when you learned of the claim denial.

Similar to initial claims, there are specific time frames that must be met for a decision to be appealed. Generally speaking, you must file an appeal no later than 60 days after you’ve learned of the company’s decision.

To learn more about filing an ERISA claim, please contact Janovksy & Associates. Attorney Janovsky will work with you to ensure you have all the appropriate paperwork to file your claim by the specific deadline. Call today to schedule a free consultation with Attorney Janovsky.

Legal Disclaimer: The information provided on this website is not legal advice, and does not establish an attorney-client relationship. The information is provided for informational purposes only.