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The Employee Retirement Income Security Act, more commonly known as ERISA (29 U.S.C. § 1001 et. seq.), is a federal law that sets standards for group health plans established by a private-sector employer, union or other employee organization that provide medical care for the plan’s participants, including the company’s employees and their dependants. ERISA regulates health insurance for most people who receive medical coverage from their employer.
If you have a legitimate health, medical or disability insurance claim, but your provider has denied your claim in violation of ERISA or because your claim was allegedly not allowed under ERISA, it is important to hire an experienced Tampa insurance lawyer.
Contact the Germain Law Group at (813) 835-8888 for a consultation about your denial of ERISA medical or disability benefits in Tampa, Florida. Attorney Michael B. Germain is knowledgeable in all areas of Florida’s insurance, claims governed by ERISA, and health and disability laws. Call the Germain Law Group today about your ERISA insurance claim denial throughout the areas in Hillsborough County, Pinellas County, Brevard County and Manatee County, Florida.
Tampa ERISA Information Center
ERISA covers most individuals who work for private-sector employees and sets standards for those employers who provide private-sector health, disability or medical benefits. Individuals with health plans provided by their employers who are not covered are typically persons who work for the government or churches.
Insurance providers governed by ERISA are required to provide individuals who are members of the plan a plan summary, plan rules, financial information about the plan and the plan’s annual report.
Individuals whose medical or disability plan is covered by ERISA are entitled to receive disclosures of important plan information, timely and fairly processing of claims benefits, receive continued group health coverage after losing their coverage, and to recover any benefits that are due under the insurance plan.
Health claims are divided into three categories under ERISA, including the following:
Additionally, disability claims can be filed with ERISA when an individual has suffered a disability while working and requests benefits to be paid under the employer’s plan.
When an individual files a claim under a policy covered by ERISA, they are required to follow the specific policies for filing a claim as set forth under their plan’s policy. It is important to look at your plan’s policies and make sure your medical issue, disability or illness is covered by your plan, and you follow every requirement when filing a claim. If you fail to do so, your claim may be denied by your insurance provider.
Medical claims are required by federal law to be decided within a specific period of time. Urgent care claims must be decided within 72 hours after the plan receives notice of the claim, and if information is missing, they must inform you more information is needed within 24 hours of filing the claim.
Pre-service claims must be decided no later than 15 days after the provider receives notice of the claim. Post-service claims must be decided no later 30 days after the provider receives notice of the claim. Disability claims must be decided no later than 45 days after the provider has received notice of the claim.
Insurance companies will often find any reason not to pay a health or medical claim that is governed by ERISA. Some reasons can include the treatment was not medically necessary, the medical condition was not covered by the plan or was preexisting, a misstatement was made on your application for the medical insurance or the medical or disability claim was made fraudulently.
If your provider denies your medical or disability claim, they are required under ERISA to send you written notice with a detailed description of why your claim was denied and how to appeal the denial. The notice must also have the plan’s rules and exclusions and any additional information that may be required if you appeal the denial.
Further, every individual has 180 days to file an appeal with their insurance provider under ERISA for a denial. They must also provide you with any documentation or records that are relevant to your claim, and they must also inform you of any medical expert whose advice they relied on when making the decisions.
Your claim must be reviewed on appeal within a reasonable time for pre-service, post-service, and disability claims, and urgent care claims must be reviewed as soon as possible. You may also be required to go through two levels of review before a decision is made on your denial.
If your insurance provider wrongfully denies your medical or disability claims or fails to follow the procedures for appealing a claim as set forth under ERISA, it is important to hire an experienced Tampa insurance lawyer who will take any necessary legal action required on your behalf.
United States Department of Labor – This website provides information on the federal Employee Retirement Income Security Act (ERISA), insurance plan requirements, answers to frequently asked ERISA questions, and miscellaneous resources about ERISA.
Employee Benefits Security Administration – The federal Employee Benefits Security Administration (EBSA) provides ERISA-governed health plan participants information on their rights under ERISA and enforces insurance providers’ compliance with the provisions of ERISA.
Disability.gov – This federal government website connects the disability community to information, programs, services and opportunities, and provides individuals with information about disability benefits in Florida.
Benefits.gov – This government website provides information about government benefits, informs citizens of government benefits they may be eligible for, and provides information on how to apply for assistance from the government.
Germain Law Group, P.A. | ERISA Attorney in Tampa
Contact the Germain Law Group today for a consultation about your ERISA claim denial in Hillsborough County, Pinellas County, Brevard County and Manatee County. Michael B. Germain is a knowledgeable Florida insurance lawyer who will listen to the facts of your situation and help you determine the best recourse in pursuing your denied medical benefits under ERISA. Contact the Germain Law Group at (813) 835-8888 for a consultation about your ERISA insurance claim denial throughout Central Florida, including Tampa, St. Petersburg, Clearwater, Titusville, Palm Bay, Melbourne, Bradenton, and Palmetto.