Employee Retirement Income Security Act (ERISA)

Employee Retirement Income Security Act (ERISA) Attorneys

Normally, employees participate in the employer’s health and retirement plans. As Columbus, Ohio and Toledo, Ohio ERISA attorneys, we understand that life events sometimes require employees to utilize the benefits of such plans, including health insurance, short and long term disability benefits, and retirement plan benefits. Whether you need assistance obtaining these benefits, you believe your employer has interfered with your rights after receiving benefits, or you are facing retaliation because you have exercised your rights, we will make sure you are taken care of every step of the way.

The Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001 – 1461, protects employees’ rights in the pursuit of your employee benefits. Specifically, ERISA prohibits employers from discharging, fining, suspending, expelling, disciplining, or discriminating against plan participants or beneficiaries for exercising or attempting to exercise their rights under ERISA or ERISA plans, or for planning to testify or otherwise taking part in any ERISA-related inquiries or proceedings. See 29 U.S.C. § 1140.

In the event you need to obtain short term and/or long term disability benefits, contact an ERISA attorney at Bryant Legal, LLC to help obtain your ERISA benefits. Additionally, if your employer has interfered with your ERISA rights or retaliated against you for exercising your ERISA rights (i.e. attempting to obtain benefits under an employer plan), call us immediately to assure your rights are protected under federal law.

For your convenience, a brief overview of ERISA and a few examples of unlawful ERISA interference/retaliation is below.

What is ERISA?

ERISA is a federal law that governs retirement and health plans that are voluntarily provided by private employers to provide protection for individual participants in these types of plans. ERISA sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.

ERISA requires plans to provide participants with plan information including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.

In general, ERISA does not cover group health plans established or maintained by governmental entities, churches for their employees, or plans which are maintained solely to comply with applicable workers compensation, unemployment, or disability laws. ERISA also does not cover plans maintained outside the United States primarily for the benefit of nonresident aliens or unfunded excess benefit plans.

Who is Protected?

ERISA § 510 covers participants in or beneficiaries of employee benefits plans governed by ERISA. See 29 U.S.C. § 1140. These participants and beneficiaries are typically employees, former employees, and members of unions or employee organizations who are eligible to receive benefits.

What can I recover under ERISA?

Participants and beneficiaries can recover benefits due to them under the terms of the plan, to enforce their rights under the terms of the plan, or to clarify their rights to future benefits under the terms of the plan. Benefits include medical, retirement, and/or disability benefits as explained more fully below.

Additionally, those pursuing benefits can recover their costs and attorneys’  fees.

What types of claims can I pursue under ERISA?

ERISA § 510 covers plan participants and beneficiaries of two types of employee benefit plans: (1) employee welfare benefit plans and (2) employee pension benefit plans.

  • (1) “Employee welfare benefit plans” (29 U.S.C. § 1002(1)) are plans established or maintained by an employer that provide welfare benefits such as:
    • Medical, surgical, or hospital care or benefits;
    • Benefits in the event of sickness, accident, disability, death or unemployment;
    • Vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid legal services; and
    • Any benefit described in section 302(c) of the Labor Management Relations Act (other than pensions on retirement or death, and insurance to provide such pensions).
  • (2) “Employee pension benefit plans” (29 U.S.C. § 1002(2)), often called retirement plans, are plans established or maintained by an employer that provide retirement income to employees, or which result in a deferral of income by employees for periods extending to the termination of employment or beyond. ERISA § 510 covers plan participants and beneficiaries of both kinds of benefit plans.

To that end, all health and disability benefit claims must be decided within a specific time limit, depending on the type of claim filed. According to the Department of Labor, below are the specific types of claims:

  • Disability claims are requests for benefits where the plan must make a determination of disability to decide the claim.
  • Group health claims are divided into three types: urgent care, pre-service and post-service claims, with the type of claim determining how quickly a decision must be made. The plan must decide what type of claim it is except when a physician determines that the urgent care is needed.
  • Urgent care claims are a special kind of pre-service claim that requires a quicker decision because your health would be threatened if the plan took the normal time permitted to decide a pre-service claim. If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim.
  • Pre-service claims are requests for approval that the plan requires you to obtain before you get medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary.
  • Post-service claims are all other claims for benefits under your group health plan, including claims after medical services have been provided, such as requests for reimbursement or payment of the costs of the services provided. Most claims for group health benefits are post-service claims.

How do I file a claim for ERISA benefits?

First, write your plan administrator, your employer’s human resource department (or the office that normally handles claims), or your employer to notify them that you have a claim. Keep a copy of the letter for your records. You may also want to send the letter by certified mail, return receipt requested, so you will have a record that the letter was received and by whom.

Second, there is a waiting period depending on the type of claim you filed.

Third, a decision is made. If your claim is denied, the plan administrator must send you a notice, either in writing or electronically, with a detailed explanation of why your claim was denied and a description of the appeal process. In addition, the plan must include the plan rules, guidelines, or exclusions (such as medical necessity or experimental treatment exclusions) used in the decision or provide you with instructions on how you can request a copy of these documents from the plan. The notice may also include a specific request for you to provide the plan with additional information in case you wish to appeal your denial.

Appealing a Denied Claim

In the event your claim is denied, you have 180 days from the date of the denial to file an appeal. It is important to have an attorney assist with the appeal process because it is crucial to obtaining your benefits and preserving the record in the event a lawsuit must be filed.

You should also be aware that the plan must provide claimants, on request and free of charge, copies of documents, records, and other information relevant to the claim for benefits. The plan also must identify, at your request, any medical or vocational expert whose advice was obtained by the plan.

If Your Appeal is Denied

In the event your appeal is denied (which is not uncommon), you have the right to bring an action in court to challenge the denial. However, you must complete your plan’s claim process before filing an action in court to challenge the denial of a claim for benefits.

Employers Cannot Interfere with your ERISA rights and Retaliation is Unlawful

Importantly, ERISA, 29 U.S.C. § 1140, prohibits your employer from (1) interfering with your ERISA rights; or (2) retaliating against you for exercising your ERISA rights (i.e. filing a claim to obtain benefits).

Specifically, “it shall be unlawful for any person to discharge, fine, suspend, expel, discipline, or discriminate against a participant or beneficiary for exercising any right to which he is entitled under the provisions of an employee benefit plan…or for the purpose of interfering with the attainment of any right to which such participant may become entitled under the plan, this subchapter, or the Welfare and Pension Plans Disclosure Act.

Additionally, “it shall be unlawful for any person to discharge, fine, suspend, expel, or discriminate against any person because he has given information or has testified or is about to testify in any inquiry or proceeding relating to this chapter or the Welfare and Pension Plans Disclosure Act.”

Examples of potential ERISA claims:

  • Interference:
    • terminating employee after he expresses a need for medical leave for upcoming extended medical treatment (i.e. surgery, etc.) is likely pretext for interference with employee’s health insurance benefits
    • accelerating an employee’s departure to avoid vesting of additional benefits in employer’s 401(k) retirement plan
  • Retaliation:
    • termination in retaliation for an appeal of denial of ERISA disability benefits
    • reducing an employee’s hours in order to avoid future costs that would become associated with its health insurance plan’s coverage because the reduction of hours deprived the employee of continued participation in employee benefit plan

For more information about  your legal rights under the Employee Retirement Income Security Act, contact a Columbus, Ohio or Toledo, Ohio ERISA attorney at Bryant Legal, LLC.

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