Know your ERISA Appeal Rights and the Claim Review Procedures for your Individual Life, Health, and Disability Insurance Coverage
Once your life, health insurance or disability claim has been denied, your first question may be, “What do I do?” Is it worth spending your time, energy, and money on an appeal when your insurance company has already made up its mind. The short answer is emphatically “YES!” Whether your medical, life insurance or disability benefits are provided through an employer-sponsored insurance plan that is governed by the federal law known as ERISA, or are provided through an individual health, life or disability income insurance policy that you purchased on your own, a targeted, well-supported appeal can be an effective tool for persuading your insurance company to overturn its decision and pay your benefits. In some cases, moreover, the appeal procedure may be mandatory, so that your failure to exhaust the appeal may cause you to lose important rights.
Claim review procedures vary depending on the type of insurance policy or plan, and the interaction of contract law with state and federal statutes.
- ERISA and Employer-Sponsored Group Life, Group Health, and Group Short and Long Term Disability Plans: Most people with health, life or disability insurance coverage have received it as a fringe employee benefit through their work (or as a family member or dependent of an employee). Such coverage is typically in the form of an employer-sponsored group plan that covers all employees. Although there are exceptions, such as church plans or plans for state employees, most employer-sponsored group plans are governed by the federal Employee Retirement Income Security Act, or ERISA. While states may still regulate some details of insurance coverage (such as whether and to what degree certain medical treatments or diagnostic procedures — mammograms, chiropractic care, etc. — must be covered by a health insurance plan), ERISA prescribes the general procedural rules with regard to disclosure of plan information, review procedures for denied claims, litigation rights, and other such matters. Follow this link for some tips from our lawyers for taking full advantage of your ERISA appeal rights with regard to a group life, health insurance or disability claim denial.
- Individual Life, Health and Disability Insurance Policies: Many people purchase their own private insurance through an agent or broker, either because they do not have, or wish to supplement, employer-sponsored group coverage. Such private coverage is typically provided through an individual insurance policy and is generally subject to state law only, i.e., without the overlay of federal ERISA law. In contrast to group disability coverage, which is generally referred to as short and long term disability coverage, individual disability insurance policies are typically called disability income coverage, and, in the case of business owners, may also include business overhead expense coverage. Follow this link for a brief summary by our lawyers of the appeal procedures for individual life, medical expense, business overhead expense, and disability income insurance claims in New York.
- Union Plans, MEWA’s, Association Plans and Other Types of Life, Medical Expense and Disability Insurance Coverage: There are a variety of other sources of health, life and disability insurance coverage, as well. These can include insurance coverage through unions, professional societies, and multiple-employer welfare associations, or MEWA’s. Coverage under such plans often raises additional, complex issues, which cannot be adequately addressed within the scope of this website.
Mark Scherzer Law :: ERISA Life, Health Insurance, and Short and Long Term Disability Claim Appeals :: Claim Denials
ERISA Disability and Health Insurance Lawyers in New York (including Manhattan, the Bronx, Queens, Brooklyn, Staten Island, Albany, Amherst, Buffalo, Cheektowaga, Hempstead, Levittown, Mount Vernon, New Rochelle, Rochester, Schenectady, Syracuse, Troy, Utica, White Plains, and Yonkers)