ERISA Overview

• ERISA Summary Plan Description (SPD) – A comprehensive document provided by the plan sponsor (typically the employer) or plan administrator that outlines the terms and conditions of the employee benefit plan governed by ERISA. It includes information about plan eligibility, coverage, claims procedures, and participant rights. Reviewing the SPD is essential to understanding the plan’s provisions and determining the basis for an appeal.

• ERISA Claims Procedure – ERISA and its implementing federal regulations establish specific guidelines for the claims and appeals process. Familiarize yourself with the procedural requirements, such as the timeframes for filing claims, the notification of denials, and the opportunity for a full and fair review. Understanding these procedures will help you navigate the appeals process effectively.

• Department of Labor (DOL) – The DOL is responsible for enforcing ERISA regulations. Their website provides valuable resources, including publications, guides, and FAQs, that offer insights into ERISA appeals. They can provide information on filing a complaint or seeking assistance with a denied claim.

• Internal Appeal – Before pursuing external remedies (a lawsuit in federal court), it is generally required to exhaust the internal appeals process provided by the plan. This involves submitting a written appeal to the plan administrator, highlighting the reasons for disagreeing with the initial denial and including evidence in support of the appeal. The plan’s SPD will outline the specific steps and deadlines for internal appeals. It will not detail the types of evidence a particular claimant will need to best support the appeal.

• ERISA Attorney – Consulting with an experienced ERISA attorney can greatly enhance your chances of success during the appeals process. An ERISA attorney can provide guidance on the complex regulations, help strengthen your case, and represent your interests if litigation becomes necessary.

• Independent Medical Examination (IME) – In some cases, a plan may require an IME to evaluate the participant’s medical condition. In some cases, it is a good idea for the claimant to get his own IME. An IME involves an assessment by an independent healthcare provider not associated with the claimant, the insurance carrier or the initial denial. Done properly by a truly disinterested provider, it can provide an unbiased, often compelling medical opinion to support your appeal. When initiated by the carrier rather than the claimant, the claimant should be aware that the provider may not have his best interests in mind. If required by the carrier, consider hiring a nurse to attend the carrier’s IME or if not, take your spouse or other trusted person to the appointment. Take notes about the condition of the practice, whether the specialty applies to the disabling condition. How long the physician spends with you, the types of questions she asks, her demeanor. Then, shortly after you return home, draft a statement based on your notes to describe your experience. If you had a poor experience, or the doctor gave you the impression that she does not believe you, submitting your statement to the carrier after the IME will make it part of the administrative record. This will help you if you have to appeal a denial or file a lawsuit. 

• ERISA Case Law – Familiarize yourself with relevant ERISA case law, as court decisions can influence the interpretation and application of ERISA provisions. Reviewing precedents can provide insights into successful arguments and strategies used in previous ERISA appeals cases. (Note, this is akin to googling your medical condition and then visiting a doctor – it can be helpful in formulating questions to ask but it does not compare to the expertise of the ERISA attorney advising you.)

• ERISA Appeal Letters – Templates and sample appeal letters can be found online, some are good, others are not. The good ones can provide a useful starting point for crafting your own appeal. These resources typically offer guidance on structuring the letter, highlighting key facts, addressing legal arguments, and presenting your case persuasively. However, every claim is unique. Handling one’s own initial claim is less risky than handling one’s own appeal. Under the law, in most cases, the only information that a judge will ever see if the claim gets litigated is whatever is contained in the administrative record. The appeal is, in most cases, the last time you will be able to provide evidence in support of your claim. For this reason, claimants should seriously consider seeking legal advice from an experienced ERISA attorney prior to appealing an ERISA benefits denial.

• Patient Advocate Organizations – Various nonprofit organizations focus on assisting patients and their families with medical claims, including ERISA-related appeals. They offer resources, education, and support throughout the process, helping you navigate complex healthcare systems. 

• ERISA-Experienced Benefit Consultants – Benefit consultants specializing in ERISA can provide valuable assistance in understanding the plan provisions, determining eligibility, and developing strong appeal arguments. They offer expertise in analyzing the claim, identifying potential errors or misinterpretations, and formulating effective strategies for success. Be sure you know whether they are also attorneys.

Remember, the information provided here is a starting point, and it is important to consult with legal or professional advisors to ensure accurate and up-to-date guidance tailored to your specific circumstances.