Understanding Your Rights Under ERISA: What Employees Need to Know
Approximately 18 percent of in‑network health claims are denied on average, though some plans report denial rates far higher. For employees unaware of their rights under the Employee Retirement Income Security Act (ERISA), a denial can mean losing access to critical care or benefits. Knowing ERISA’s safeguards isn’t optional—it’s essential to make sure you obtain the coverage and support the law promises.
If you’re facing a denied disability in California, work with an experienced ERISA attorney and get the assertive advocacy your case demands.
What Is ERISA and Which Benefits Does It Cover?
ERISA is a federal law that sets minimum standards for most voluntary retirement, health, disability, and life insurance plans in private industry. It governs how plans are managed, what information must be disclosed, and how claims and appeals are processed. ERISA does not apply to government, church, or individual private insurance policies. In California, ERISA covers nearly all group plans provided by private employers—including short-term and long-term disability, medical, dental, vision, accidental death, and pension plans.
Who Is Responsible for Managing My Benefits?
Under ERISA, the “plan administrator” is legally required to act as a fiduciary—meaning they must manage your benefit plan solely in your best interest. They must provide you with a Summary Plan Description explaining your rights and must process claims fairly, without unnecessary delays. Failure to follow these rules can lead to legal penalties and possible damages. If you are unsure who administers your plan, ask your employer or review your plan documents.
Why Might a Disability Claim Be Denied?
Common reasons for denial include insufficient medical evidence, missed deadlines, or a determination that your condition does not meet the plan’s definition of “disability.” Insurance companies may also cite pre-existing condition exclusions, incomplete application forms, or procedural errors. Disability lawyers routinely handle denials for clients across California and the United States, working to overturn unjust decisions and ensure fair process.
When and How Can I Appeal a Denied ERISA Claim?
If your claim is denied, ERISA requires that you receive a written explanation, including the specific reasons for denial and instructions for appealing. Most plans give you 180 days to file an appeal, during which you can submit additional evidence (medical records, doctor letters, witness statements) and legal arguments. The plan administrator must then make a final decision—usually within 45 and the insurance company is entitled to one extension of 45 days. If your appeal is denied, the insurance company will either give you an additional opportunity to appeal or let you know that you can file a lawsuit in federal court.
Which Legal Remedies Are Available Under ERISA?
If you prevail in your ERISA lawsuit, you may recover unpaid benefits, interest, and sometimes attorney’s fees, if your case goes to trial and you prevail. Courts can also order the plan to provide information or clarify rights to future benefits. In cases involving fiduciary breaches or bad faith conduct, additional remedies may be available. However, ERISA does not permit punitive or emotional distress damages, making strong legal advocacy from a denial claims lawyer essential.
What Should I Do If I Get a Denial Letter?
Take immediate action. Save the denial letter, request your entire claim file, and avoid giving up or accepting the decision as final. Reach out to an experienced ERISA attorney at Todd Krauss, APC for a confidential, no-obligation evaluation. Delays can be fatal to your case, so act promptly. Contact us today to speak directly with an ERISA lawyer and get the protection the law provides.
