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ERISA Or Not (ERISA Claims)

Texas Employee Benefits and ERISA

ERISA, properly known as the Employee Retirement Income Security Act of 1974, covers employer-provided benefits such as life insurance, accidental death insurance, long and short-term disability insurance, health insurance and retirement plans such as 401K plans. ERISA applies to private employers who provide these benefits generally called “plans” but ERISA does not require employers to offer “plans” or ERISA benefits. Simply because these benefits are provided does not automatically make them governed by ERISA. For example, ERISA does not apply to life, health, accident, and disability insurance purchased by individuals. It is an understatement to say that understanding ERISA can be confusing and discouraging.

At The Law Office of Mark A. Ticer, we represent individuals in disputes with their employers and their employer-ERISA Plans. As an ERISA lawyer, Mark Ticer uses his knowledge and experience of ERISA laws and practice to help clients obtain the ERISA based benefits they are entitled to. Our firm is experienced in assisting people facing challenges with ERISA plans overseen by insurers or plan administrators who act arbitrarily.

ERISA or Not?

Understandably, many people are confused about ERISA and the distinctions between ERISA controlled benefits and those that are not. But the differences are important and critical – the difference between obtaining benefits or not. Mark A. Ticer helps people understand ERISA benefits and coverage and the distinctions between non-ERISA benefits and ERISA law in order to successfully obtain ERISA based benefits.

To determine whether a benefit, like health or disability coverage, is covered by ERISA, the following questions should be considered:

  • Who do I work for? If your employer is a public entity or a religious organization, you are not covered by ERISA.
  • Who pays the premiums? If your employer pays some or all of the premiums, chances are it is likely an ERISA-covered benefit. If you pay all premiums, it is likely not controlled by ERISA.
  • Who is my contact? If your contact person is called the plan administrator, then you could likely be covered by an ERISA plan.
  • What kind of insurance is at issue? If your dispute is over homeowners or automobile insurance, it is not an ERISA matter. If the problem is with employer-paid insurance like health or disability coverage, it could be governed by ERISA.

Just like regular insurance companies, employer-sponsored insurance is also in business to save money and minimize benefits and payments. For instance, plan administrators often deny initial claims, especially for disability and significant medical expenses with the hope that such denials will not be challenged or an “administrative appeal” not pursued.

The first stage of an ERISA claim is a basic claim submitted to the plan administrator or its designee. Here is where the initial decision on a claim is made. A plan beneficiary (a claimant) often does fare well at this stage.

The second phase of an ERISA claim is known as an administrative appeal and is frequently overseen by the ERISA Plan, its representative/administrator, or even insurer. This is a critical part of the claim because all information (except in very limited circumstances) must be supplied to the ERISA Plan administrator and cannot later be supplemented or added in any subsequent litigation. If the claimant loses the administrative appeal, he can file a lawsuit but must do so properly and timely (third and last phase).

ERISA matters are not for the inexperienced, do-it-your-selfers or faint of heart. There are so many pitfalls in an ERISA claim that can result in loss of benefits that an experienced and knowledgeable ERISA claims lawyer is essential. The failure to include all information, materials, reports, and proof in an “administrative record” or even understand what that means or includes is one of the most frequent and critical errors that result in a failure of success to obtain deserved ERISA based benefits.

Given the complex and detailed nature of ERISA claims, rules and laws, it is essential to obtain legal advice and representation to navigate this process.

The Law Office of Mark A. Ticer can and does provide legal advice on ERISA claims.

Contact our Dallas law firm to learn more about ERISA-covered benefit plans and how our firm might assist you in obtaining ERISA benefits.