Can I appeal a denied ERISA claim?

Many Colorado businesses choose to provide their employees with a self-funded insurance plan. Unlike traditional insurance plans where employers pay the insurance company a premium, a self-funded plan requires the employer to pay for the benefits themselves. These self-funded plans are usually covered under the ERISA law.

What is ERISA?

ERISA stands for the Employee Retirement Income Security Act. Passed in 1974, it sets minimum standards for how self-funded private employee health benefits are handled. This includes how they are administered, how they’re financed and how claims are to be processed. Not all insurance plans are covered under ERISA.

This law mainly covers self-funded plans that are provided by private employers. Employers that are not private such as government agencies do not qualify for protection under this law. Some other examples of exempt insurance plans include Medicaid, Medicare, workers’ compensation, churches, military, public workers and individually purchased insurance plans.

How to handle an appeal

Sometimes self-funded insurance providers may deny a patient’s claim. This is typically due to the fact that they believe the medical treatment administered was not medically necessary or the service is not covered. In the event that your insurance claim was denied, you have the right to appeal it.

To appeal a denied claim, you can have your doctor or attorney work on your behalf with the insurance company. If you decide to have your doctor handle the appeal, they will need to sign formal documents naming them an authorized representative of your claim. These documents are called an Assignment and Designation of Authorized Representative.

In a perfect world, all of our medical treatments would be covered underneath our insurance plan. Unfortunately, insurance providers commonly deny claims that are valid, and patients have to appeal these claims. If you find yourself in a situation where your insurance claim was denied, it’s a good idea to seek out professional legal assistance to establish your appeal.