The Obama Administration has been desperately trying to reform healthcare and health insurance in these United States and, plainly stated, ‘it aint easy.’ Trying to get Congress to agree on a plan is like herding cats. And insurance companies clearly don’t feel that reform is justified, or even necessary. Blue Cross, as but one example, has recently been trying to justify substantial health insurance rate increases. Increases. So much for reform. Many people, a lot of people in fact, have lost their jobs and are struggling to put food on the family table and to pay their delinquent mortgages. Coming up with additional funds to pay for the extravagant salaries of health insurance company executives just isn’t an option for most people these days. Reform is not only necessary, it is imperative.
And no area in health care and health insurance needs more reform than that governed and regulated by ERISA. “E-what” you say? ERISA. If you are fortunate enough to be employed, and your employer is financially able to provide health care coverage for its employees, you may have heard of the acronym of ERISA. It stands for the Employee Retirement Income Security Act. First enacted in 1974, ERISA was a laudable attempt by our federal legislators to regulate pension and retirement plans from monkey-business by employers who established such plans for their workers. Raiding company pensions, refusing to fund retirement benefits: those were the initial targeted abuses of the ERISA Act. Unfortunately, many years ago, the Act was seized upon by insurance companies as a means to avoid traditional regulation of company-sponsored health insurance plans. By the deeming of such plans to be part and parcel of “employee benefit plans,” insurers have been successful in removing these plans from regulation by State Departments of Insurance AND by traditional lawsuits in State Courts. Unlike private health and disability insurance policies (and other insurance contracts whose premiums are not funded by employers, e.g., auto policies, homeowner policies, life insurance policies, etc.), participants in ERISA-regulated policies have no relief in Court for the ‘bad faith’ conduct of insurers. Claims for emotional distress, consequential damages from the loss of denied benefits (damages to credit, the need to borrow money, loss of property, among them), and punitive damages - the biggest legal threat posed to insurers who cavalierly deny claims - are unavailable to litigants in ERISA actions.
That’s the bad news. The good news is that one does have rights and remedies under ERISA. Successful litigants in an ERISA action are able to recover the benefits due them under their policies AND (at the discretion of the Court) the attorney’s fees incurred in the process. Other good news includes a fairly fast litigation track in Federal Courts (or at least faster than frequently clogged State Courts), reduced filing and litigation fees, and a significantly more streamlined litigation process. While one is generally not entitled to a jury trial in an ERISA case, there is essentially no ‘discovery’ that is conducted, meaning no costly deposition and/or trial preparation costs.
The further good news is that there ARE attorneys who handle ERISA actions. Lawyers at the Law Offices of Marc E. Grossman are those ERISA attorneys. If you are insured under a company-sponsored disability or health insurance policy, and have had a claim for benefits under such a policy denied by an insurance company, you may have a valid claim, and a viable lawsuit, under ERISA. While the standards which govern such a case can and do vary, depending on the level of administration and involvement of the insurer (vs. the employer) in determining benefits, and there are other factors which may indeed take certain claims outside of the ERISA context (factors which include the nature and status of the employer [e.g., a public employer such as a County or State agency or a religious organization]), an ERISA action can result in the recovery of denied benefits. Qualified attorneys, such as those at Marc Grossman’s office, can assess and determine whether you have an ERISA claim that can be successfully pursued.
Health insurance reform, including that regarding ERISA regulation, is clearly long overdue. In the meantime, those that have had insurance benefits denied under an employer funded insurance policy have rights that may be properly vindicated. If you believe that your ERISA claim has been improperly rejected by your insurer, contact the Law Offices of Marc E. Grossman.