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Enforcing a health benefits plan under ERISA

The Employee Retirement Income Security Act is a federal statute intended to protect workers' rights under various benefit plans that may be provided by an employer. ERISA does not require New Jersey employers to provide specific kinds of plans, but once an employer offers a benefit plan, it must obey ERISA's requirements for processing and granting or denying claims.

Health benefit plans are among the most popular employee benefit plans, but they can also be troublesome because the medical judgments required to support a claim for benefits may be open to dispute. Many employees have filed claims for health care under a plan subject to ERISA only to have the benefit claim denied by the plan administrator. While ERISA provides an internal appeal procedure, most employees with disputed claims turn to the federal courts to secure their rights under the plan.

To succeed, a legal challenge to a decision of the plan administrator must show that the administrator violated the terms of the plan. Many challenges succeed because the claimant was able to show that the plan administrator ignored pertinent medical evidence. Other successful challenges to decisions by plan administrators have shown that a decision improperly favored the interests of the employer or the insurer that provides the health care benefit. Another tactic involves showing that the plan failed to provide written notification to the claimant about pertinent plan provisions. Plan benefit statements occasionally omit language that may favor the employee's claim. If the court agrees, the administrator will be directed to grant the benefit and pay the employee's legal fees.

Anyone with a claim for health care that has been denied may wish to consult an experienced employee benefits attorney for advice on available legal remedies.

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