Many employees in New Jersey and around the country have health plans through their employers that are regulated by the Employee Retirement Income Security Act (ERISA). This law establishes the standards and procedures for making claims for benefits and appealing denials. In general, ERISA places an upper limit of 90 days to receive a decision although insurers may respond sooner. However, regulations require faster responses for some types of claims.
Urgent claims and preauthorizations
Ninety days is far too long to know if benefits will cover your urgent need. In such situations, your plan provider must issue a response within 72 hours. You must get a decision about a preservice claim seeking preauthorization for a desired treatment within 15 days.
After treatment and disability
When events force you to seek treatment without approval, you can file post-service claims. In that case, you should get a response within 30 days. As for disability claims, your insurer has 45 days to approve or deny them.
Insurers can deny claims and do so quite frequently. They should inform you in writing and explain the reason for the denial or if more information is needed to make a decision. The denial letter must explain the deadline for filing an appeal and where to send your documentation for review. Meeting this deadline is important for protecting your rights. You have the option of authorizing a representative to help you with the appeal.
Even if your appeal still results in rejection, it is not the last word on it. You may ask the U.S. Department of Labor (DOL) to review your appeal. Regional offices of the Employee Benefits Security Administration handle these secondary appeals when people believe that they have been wrongfully denied benefits.