The ERISA claims and appeals process

On Behalf of | Aug 12, 2021 | ERISA

Residents of Hackensack and other areas of New Jersey may want to learn more about how to file and appeal claims under ERISA, which stands for the federal Employee Retirement Income Security Act. Here are the steps for a self-insured employer’s plan.

1. Contact your insurance

Ask your insurance company or employer’s HR department for the claims procedure. It should be in writing. If you already know the procedure, skip this step.

2. Your insurance company sends you the procedure

There is no charge for this service. It is free.

3. You file a claim

Your insurance may ask for detailed information; it will inform you of the deadline for sending it. ERISA determines these deadlines. Your claim may involve the following:

  • Urgent care
  • Preservice
  • Postservice
  • Disability

4. Your insurance company approves or denies the claim

The time frame to receive approval will vary. Then, it will be either approved or denied. If there is a denial, you have the right to appeal. Note that insurance companies are not required to send written notifications of approval.

5. You file your appeal before the deadline

This deadline will be within the denial letter. It’s important not to miss this deadline, or your appeal will likely be dismissed.

6. The insurance company reviews your appeal

The insurance company will make a review of your appeal to the first decision. Then, the insurer will approve or deny your appeal. You will receive the decision in writing through the mail.

What happens if the appeal receives denial?

You can then appeal through the U.S. Department of Labor. You should contact your regional U.S. Department of Labor Employee Benefits Security Administration with the information.

At the present time, ERISA does not apply to individually purchased insurance plans. You can find more information about ERISA through the U.S. Department of Labor website.